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Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/practiceofmedici01gibs 


TEXT-BOOK    OF   MEDICINE. 


PRACTICE 


OF 


MEDICINE 

BY     EMINENT     MEDICAL 
SPECIALISTS  AND  AUTHORITIES 


EDITED     BY 

GEORGE     ALEXANDER     GIBSON 

M.D.,  D.Sc,  F.R.C.P.Ed. 

PHYSICIAN    TO    THE    ROYAL    INFIRMARY,     EDINBURGH 


VOL.  I. 


PHILADELPHIA 

J.     B.     L  I  P  P  I  N  C  O  T  T     COMPANY 

EDINBURGH    rd    LONDON  :    YOUNG   J.    PENTLAND 

igoi 


PREFACE. 


A  considerable  lapse  of  time  has  occurred  since  the  publication  in  this 
country  of  a  text-book  similar  to  that  now  submitted  to  the  public. 
The  advances  in  every  branch  of  medicine  have  during  the  interval  been 
so  great  as  to  create  a  want  for  a  work  reflecting  modern  English 
teaching,  and  it  has  been  felt  that  this  can  be  most  satisfactorily  met  by 
the  united  efforts  of  several  writers  who  represent  different  important 
schools  in  the '  United  Kingdom. 

In  arranging  the  scheme  and  determining  the  scope  of  the  work,  certain 
points  have  demanded  consideration,  and  it  has  by  no  means  been  easy  to 
arrive  at  a  decision  regarding  them.  The  wisdom  of  including  a  prelimin- 
ary discussion  of  general  etiological  and  pathological  problems,  by  way  of 
introduction  to  the  more  practical  portion  of  the  work,  has  been  care- 
fully weighed,  and  the  conclusion  reached  that  such  a  section  would  be 
of  real  utility.  The  position  of  cutaneous  diseases  has  also  been  a  subject 
of  anxious  deliberation.  Although  fully  recognising  that  in  every  medical 
school  Dermatology  ought  to  have  the  thorough  teaching  which  can  only 
be  given  by  a  specialist,  it  has  seemed  inexpedient  to  exclude  diseases  of 
the  skin  from  a  text-book  on  the  Practice  of  Medicine.  Another  matter 
requires  a  word  of  remark.  Certain  symptoms,  occasionally  dignified  by 
the  title  of  separate  diseases,  will  be  sought  in  vain  under  individual 
headings,  but  will  be  found  as  parts  of  the  subjects  to  which  they  properly 
belong. 

It  only  remains  for  the  Editor  to  return  his  grateful  thanks  to  all  his 
coadjutors  for  the  unfailing  consideration  and  loyal  support  which  they 
have  rendered  in  the  production  of  these  volumes,  and  to  express  the 
profound  regret  occasioned  by  the  death,  during  the  progress  of  the  work, 
of  Professor  Kanthack,  which  has  inflicted  a  grievous  loss  on  scientific 
medicine 

G.  A.  GIBSOK 

Edinburgh,  April  1901. 


LIST  OF  CONTRIBUTORS. 


AFFLECK,  J.  O.,  M.D.,   F.R. C.P.Ed.,  Consulting   Physician    to    the    Royal 
Infirmary,  Edinburgh. 

ASHBY,   HENRY,   M.D.,   F.R.C.P.,  Physician  to  the   General   Hospital   for 
Children,  Manchester. 

AULD,    A.    G.,    M.D.,    M.R.C.P.,    Late    Assistant    Physician    to    the    Royal 
Infirmary,  Glasgow. 

BRADFORD,  JOHN    ROSE,   M.D.,   D.Sc,   F.R.C.P.,   F.R.S.,  Physician   to 
University  College  Hospital,  London. 

BRUCE,  ALEXANDER,   M.A.,   M.D.,  F.R.C.P.Ed.,  Assistant   Physician   to 
the  Royal  Infirmary,  Edinburgh. 

BRUCE,  J.  MITCHELL,  M.A.,  M.D.,  LL.D.,  F.R.C.P.,  Physician  to  Charing 
Cross  Hospital,  London. 

BRUNTON,  Sir  LAUDER,  M.D.,  D.Sc,  LL.D.,  F.R.C.P.,  F.R.S.,  Physician 

to  St.  Bartholomew's  Hospital,  London. 

COLMAN,    W.    S.,    M.D.,    F.R.C.P.,    Assistant    Physician    to    St.    Thomas's 
Hospital,  London. 

GIBSON,  G.  A,  M.D.,  D.Sc,  F.R.C.P.Ed.,  Physician  to  the  Royal  Infirmary, 
Edinburgh. 

GILLESPIE,    A.    LOCKHART,    M.D.,   F.R.C.P.Ed.,   Medical    Registrar    to 
the  Royal  Infirmary,  Edinburgh. 

GOWERS,   Sir  WILLIAM  R.,  M.D.,  F.R.C.P.,  F.R.S.,  Consulting  Physician 
to  University  College  Hospital,  London. 

HARRIS,  V.  D.,  M.D.,  F.R.C.P.,  Physician  to  the  City  of  London  Hospital 
for  Diseases  of  the  Chest. 

HAWKINS,  HERBERT  P.,  M.A.,  M.D.,  F.R.C.P.,  Physician  to  St.  Thomas's 
Hospital,  London. 

JAMIESON,  W.  ALLAN,  M.D.,  F.R.C.P.Ed.,  Physician  for  Diseases  of  the 
Skin  to  the  Royal  Infirmary,  Edinburgh. 

KANTHACK,  A.   A.,   M.D.,   F.R.C.P.,   Late  Professor  of  Pathology  in  the 
University  of  Cambridge. 

KER,  CLAUDE  B.,  M.D.,  F.R.C.P.Ed.,  Medical  Superintendent  of  the  City 
Hospital,   Edinburgh. 

LAWRENCE,  T.  W.  P.,  M.B.,  F.R.C.S.,  Curator  of  the  Museum  of  Anatomy, 
University  College,  London. 

LUFF,  A.  P.,  M.D.,  B.Sc,  F.R.C.P.,  Physician  to  St.  Mary's  Hospital,  London. 


viii  LIST  OF  CONTRIBUTORS. 

MACKENZIE,  HECTOR,  M.A.,  M.D.,  F.R.C.P.,  Physician  to  St.  Thomas's 
Hospital,  London. 

MANSON,  PATRICK,  C.M.G.,  M.D.,  LL.D.,  F.R.C.P.,  F.R.S.,  Lecturer  on 
Tropical  Diseases,  London  School  of  Tropical  Medicine. 

MARTIN,  SIDNEY,  M.D.,  B.Sc,  F.R.C.P.,  F.R.S.,  Physician  to  University 
College  Hospital,  London. 

MOORE,  Sir  JOHN  WILLIAM,  B.A.,  M.D.,  F.R.C.P.I.,  Physician  to  Meath 
Hospital,  Dublin. 

MOTT,  F.  W.,  M.D.,  F.R.C.P.,  F.R.S.,  Physician  to  Charing  Cross  Hospital, 
London. 

OLIVER,  THOMAS,  M.A.,  M.D.,  F.R.C.P.,  Physician  to  the  Royal  Infirmary, 
Newcastle-on-Tyne. 

PASTEUR,  W.,  M.D.,  F.R.C.P.,  Physician  to  Middlesex  Hospital,  London. 

PHILIP,  R.  W.,  M.A.,  M.D.,  F.R.C.P.Ed.,  Assistant  Physician  to  the  Royal 
Infirmary,   Edinburgh. 

RUSSELL,  S.  RISIEN,  M.D.,  F.R.C.P.,  Assistant  Physician  to  University 
College  Hospital,  London. 

RUSSELL,  WILLIAM,  M.D.,  F.R.C.P.Ed.,  Assistant  Physician  to  the  Royal 
Infirmary,   Edinburgh. 

STOCKMAN,  RALPH,  M.D.,  F.R.C.P.Ed.,  Professor  of  Materia  Medica  and 
Therapeutics  in  the  University  of  Glasgow. 

TAYLOR,  FREDERICK,  M.D.,  F.R.C.^  Senior  Physician  to  Guy's  Hospital, 
London. 

TAYLOR,  JAMES,  M.A.,  M.D.,  F.R.C.P.,  Physician  to  the  National  Hospital 
for  the  Paralysed  and  Epileptic,  London. 

TURNER,  W.  ALDREN,  M.D.,  F.R.C.P.,  Assistant  Physician  to  King's 
College  Hospital,  London. 

WHITE,  W.  HALE,  M.D.,  F.R.C.P.,  Physician  to  Guy's  Hospital,  London. 

WILLIAMSON,  R.  T.,  M.D.,  F.R.C.P.,  Physician  to  Ancoats  Hospital, 
Manchester. 

WOOD,  G  E.  CARTWRIGHT,  M.D.,  B.Sc,  Superintendent  of  the  Bacterio- 
logical Department  of  the  Laboratories  of  the  Royal  Colleges  of  Physicians 
(London)  and  Surgeons  (England). 

WOODHEAD,  G  SIMS,  M.D.,  F.R.C.P.Ed.,  Professor  of  Pathology  in  the 
University  of  Cambridge. 


CONTENTS  OF  VOLUME  FIRST. 


INTRODUCTION. 
The  General  Pathology  of  Disease. 


The  Reactions  of  the  Body  and  its  Tissues 
Cloudy  Swelling    . 
Fatty  Changes 
Amyloid  Changes  . 
Hyaline  and  Waxy  Degeneration 
Colloid  Changes     . 
Mucous  Changes    . 
Wasting  and  Atrophy     . 
Necrosis  and  Necrobiosis 
Calcification  and  Concretions  . 
Pigmentation 
Acute  Inflammation 
Chronic  Inflammation    . 
Regeneration  and  Repair 
Metaplasia     .... 
Hypertrophy 

Pathology  of  Bacterial  Infection  . 
Characters  of  Bacteria    . 
Requirements  of  Bacterial  Life 
Vital  Manifestations  of  Bacteria 
Infection 
Predisposition 
Contagion 
Immunity 
Immunisation 
Theory  of  Immunity 
Serum  Therapeutics 
Toxaemia 

Treatment  by  means  of  Organic  Extracts 
Preventive  Inoculation  . 


1 

2 

2 

6 

9 

10 

10 

11 

12 

14 

15 

18 

35 

40 

41 

42 

43 

44 
46 
48 
53 
59 
C2 
64 
66 
75 
81 
87 
93 
98 


SECTION  I. 
General  Diseases. 


Typhus  Fever 
Relapsing  Fever 
Typhoid  Fever 


100 
113 

118 


CONTENTS. 


Variola  and  Yaccinia   . 

Varicella — Chickenpox 

Morbilli — Measles — Rubeola 

Scarlatina — Scarlet  Fever    . 

Rubella — Roseola  Epidemica — Rubeola  Notha 

Pertussis — Whooping-Cough 

Mumps — Epidemic  Parotitis 

Influenza — Epidemic  Catarrhal  Fever 

Diphtheria  . 

Erysipelas    . 

Septic  Diseases 

Sapraeniia 

Septicaemia 

Pyaemia 

Acute  Pneumonia 

Tetanus        ..... 

Epidemic  Cerebro-Spinal  Meningitis 

Bubonic  Plague   .... 

Cholera       .         .  . 

Dysentery   ..... 

Liver  Abscess  of  Warm  Climates 

Mediterranean  Fever  . 

Sprue . 

Dengue 

Yellow  Fever 

Beriberi 

Yaws  . 

Verruga 

Malaria  and  Malarial  Disease 

General  Gonorrhceal  Infection 

Syphilis       .... 

Tuberculosis 

Acute  Miliary  Tuberculosis 
Tuberculosis  of  the  Alimentary  System 

Mouth  and  Tongue 

Pharynx  and  Tonsils 

(Esophagus,  Stomach,  and  Duodenum 

Intestine 

Liver  and  Pancreas 
Tuberculosis  of  the  Lymphatic  System 

Lymphatic  Glands . 

Spleen  . 

Lymphatics    . 
Tuberculosis  of  the  Vascular  System 
Tuberculosis  of  the  Serous  Membranes 

Pleura  ..... 

Pericardium  .... 

Peritoneum    .... 

Multiple  Serous  Tubercle 
Tuberculosis  of  the  Respiratory  System 

Nose      ..... 


CONTENTS. 


Tuberculosis — continued. 

Larynx.  .... 

Trachea  and  Bronchi 

Lungs    ..... 

Acute  Pneumonic  Phthisis 

Chronic  Pulmonary  Tuberculosis 
Tuberculosis  of  the  Genito-Urinary  System 

Urinary  Organs 

Testicle  .... 

Female  Generative  Organs 

The  Breast    .... 
Tuberculosis  of  the  Integumentary  System 

Lupus  Vulgaris 

Other  Forms  of  Cutaneous  Tubercle 
Tuberculosis  of  the  Nervous  System 

Chronic  Meningitis 

Tuberculous  Tumours  of  the  Brain 


and  Cord 


Leprosy       .... 
Actinomycosis 
Hydrophobia — Rabies 
Anthrax      .... 
Glanders     .... 
Snake-Bite  .... 

Gout 

Acute  Rheumatism  or  Rheumatic 
Chronic  Rheumatism  . 

Muscular  Rheumatism    . 
Rheumatoid  Arthritis  . 
Rickets        .... 

Foetal  Rickets,  Osteo-Genesis 

Late  Rickets 

Fragilitas  Ossium 
Osteo-Malacia — Mollities  Ossium 
Diabetes  Mellitus 
Diabetes  Insipidus 
Sunstroke    .... 
African  Lethargy 


Fever 


Imperfecta 


Achondro 


plasia 


398 
403 
403 
404 
406 
433 
433 
436 
437 
438 
439 
439 
441 
442 
443 
443 

444 
448 
450 
453 
456 
459 
460 
472 
479 
480 
481 
489 
498 
498 

503 
504 
505 
519 
522 
525 


SECTION   II. 


Diseases  caused  by  Animal  Parasites. 


Protozoa 

Rhizopoda 

Gregarinida3 
Infusoria 

Annuloida  . 
Cestoda 
Trematoda 
Nematoda 


527 
527 
528 
530 

532 
532 
538 

544 


CONTENTS. 


SECTION  III. 

Diseases  caused  by  Chemical  Substances. 

Lead  Poisoning 

Lead  Poisoning  in  Children 
Arsenical  Poisoning  . 
Phosphorus  Poisoning 
Mercurial  Poisoning  . 
Alcoholic  Poisoning  . 
Meat  or  Ptomaine  Poisoning 

Poisoning  by  Vegetable  Alkaloids  and  other  active  Principles 
Poisoning  by  Grain,  Ergotism,  and  Pellagra 
Lathyrism. 


SECTION  IV. 

Alimentary  System. 


Diseases  of  the  Mouth 
Stomatitis     . 

Catarrhal  Stomatitis 
Aphthous  Stomatitis 
Gum-boil 

Diseases  of  the  Tongue 

Ulceration    . 

Traumatic  Ulceration 
Dyspeptic  Ulceration 
Syphilitic  Ulceration 
Tuberculosis 
Cancerous  Ulceration 

Tumours       .  .  . 

Inflammation 

Atrophy 

Hypertrophy 

The  Tongue  as  an  Index  of 

Diseases  of  the  Salivary  Glands 
Functional  Disorders 
Organic  Diseases 

Diseases  of  the  Fauces  and  Tonsils 
Acute  Tonsillitis  . 
Follicular  Tonsillitis 
Chronic  Tonsillitis 

Diseases  of  the  Pharynx 

Pharyngitis  . 
Diseases  of  the '(Esophagus 
Inflammation 
Diverticula  . 
Dilatation  . 
Stricture 

Spasmodic  Stricture 
Malignant  Stricture 


Disease 


CONTENTS. 


xiu 


Diseases  of  the  Stomach 
Introductory 
Gastric  Indigestion 

Gastric  Irritation  . 

Gastric  Insufficiency 

Nervous  Dyspepsia 
Gastritis        .... 

Acute  Catarrhal  Gastritis 

Chronic  Catarrhal  Gastritis 

Acute  Toxic  Gastritis     . 

Infective  Gastritis 
Atrophy  and  Degenerations    . 
Cirrhosis       .... 
Haemorrhage 
Gastric  Ulcer 

Cancer  .... 

Dilatation     .... 

Diseases  of  the  Intestines    . 

Enteritis       .... 

Catarrhal  Enteritis 

Catarrhal  Enteritis  in  Children 

Cholera  Nostras 

Cholera  Infantum 

Croupous  or  Diphtheritic  Enteritis 

Phlegmonous  Enteritis  . 

Mucous  Colitis 

Ulcerative  Colitis  . 
Intestinal  Obstruction    . 
Constipation 
Appendicitis  .  -  . 

Diseases  of  the  Liver 

Jaundice       .... 
Catarrh  of  the  Common  Duct 
Acute  Yellow  Atrophy 
Icterus  Neonatorum 
Nervous  Jaundice 
Gallstones     .... 
Active  Hypersemia  of  the  Liver 
Diseases  of  the  Portal  Vein    . 
Diseases  of  the  Hepatic  Artery 
Abscess  of  the  Liver 

Multiple  Small  Abscesses 

Single  Large  Abscesses 
Cirrhosis  of  the  Liver    . 

Alcoholic  Cirrhosis 

Hypertrophic  Cirrhosis 

Malarial  Cirrhosis 

Saturnine  Cirrhosis 

Other  Forms  of  Cirrhosis 
New  Formations  in  the  Liver 

Malignant  Disease 

Secondary  Cancer 

Primary  Carcinoma 

Primary  Carcinoma  of  the  Gall  Bladder 

Primary  Carcinoma  of  the  Bile  Ducts 


PAGE 

649 
649 
654 
655 
660 
661 
670 
670 
673 
677 
678 
678 
679 
679 
682 
693 
697 

703 
703 
703 
705 
710 
711 
713 
714 
714 
716 
717 
731 
735 

746 
748 
752 
753 
755 
756 
756 
768 
769 
769 
770 
770 
771 
774 
774 
779 
779 
780 
780 
780 
780 
781 
783 
784 
784 


CONTENTS. 


Diseases  of  the  Liver — continued. 

Sarcoma  of  the  Liver 

Pigment  Tumours  of  the  Liver 

Angioma 
Secondary  Affections  of  the  Liver 

Passive  Hyperemia 

Fatty  Degeneration 

AVaxy  Degeneration 

Syphilis 

Actinomycosis 

Tuberculosis 
Hydatid  of  the  Liver 
Other  Cysts  .... 
Perihepatitis 

Diseases  of  the  Pancreas 

Cirrhosis       .... 
Atrophy        .... 

Fatty  Changes 

Calculi  .... 

Malignant  Disease 
Primary 

Secondary  Growths 
Malignant  Adhesions 

Pancreatic  Cysts    . 

Tubercle       .... 

Acute  Pancreatitis 

Hemorrhagic  Pancreatitis 
Suppurative  Pancreatitis 
Gangrenous  Pancreatitis 

Haemorrhage 

Fat  Necrosis 

Diseases  of  the  Peritoneum 

Introductory 

Peritonitis     .... 
Acute  Peritonitis    . 
Chronic  Peritonitis 
Tuberculous  Peritonitis . 
Tabes  Mesenteric^ 
Malignant  Peritonitis 
Syphilitic  Peritonitis 

Simple  Tumours  . 

Peritoneal  Fluids  and  Ascites 


LIST    OF  ILLUSTRATIONS. 


FIG. 

1.  Fatal  case  of  typhus  in  a  male  adult ;  examples  of  the  temperature  curve 

during  the  period  of  invasion      ...... 

2.  A  case  of  typhus  in  a  young  adult  ;  examples  of  termination  by 

3.  Complete  course  of  typhus  in  a  child,  set.  4 

4.  Complete  course  of  typhus  in  a  woman,  set.  67  ;  rare  instance  of  termina 

tion  by  lysis       ........ 

5.  A  case  of  relapsing  fever  (after  Muirhead) 

6.  A  moderately  severe  case  of  typhoid  fever  in  a  female,  set.  22 

7.  A  severe  case  of  typhoid  fever,  showing  a  tendency  to  hyperpyrexia  on  the 

twenty-sixth  day         ....... 

8.  Case  of  a  female,  set.  1 7,  terminating  fatally  by  haemorrhage 

9.  Fatal  termination  by  perforation  in  a  female,  set.  22 

10.  A  mild  or  abortive  case  of  typhoid  fever 

11.  Smallpox  mortality  curve 
12—13.  Discrete  smallpox 

14.  Coherent  smallpox — secondary  fever 

15.  Confluent  smallpox — severe  secondary  fe\> 

16.  Malignant  smallpox 

1 7.  Measles  mortality  curve  . 

18.  Ordinary  measles    .... 

19.  Defervescence  in  measles 
20—21.  Measles  after  scarlatina 

22.  Scarlatina  mortality  curve 

23.  Enteric  fever  mortality,  curve  . 
24—25.  Simple  scarlatina 

26.  Anginose  scarlatina 

27.  Ataxic  scarlatina    .... 

28.  Malignant  scarlatina 

29.  Influenza — cardio-pulmonary  . 

30.  ,,  gastric  .... 

31.  „  febrile  .... 
32—34.  Influenza  in  child 

35.  Temperature  in  erysipelas 

36.  Temperature  chart  from  a  case  of  acute  septicaemia  ending  in  recover}' 

37.  ,,  ,,      a  fatal  case  of  pyamiia 

38.  Parasite  of  tertian  malaria       .... 

39.  Evolution  of  the  benign  tertian  parasite  (compiled  from  Mannaberg) 

40.  Evolution  of    the    flagellated  body  in  the  tertian  and  quartan  parasites 

(compiled  from  Thayer  and  Hewetson)         .... 

41.  Malaria  parasite  ;  evolution  of  the  flagellated  body  from  the  crescent 

42.  Microgametocyte  emitting  four  microgametes  (flagella) 

43.  Transformation  of  the  zygote  in  the  stomach  wall  of  the  mosquito  (after 

Grassi)      .......... 

44.  Zygotes  protruding  on  the  outer  surface  of  the  mosquito  (after  Ross) 

vol.  I. — b 


102 
103 

104 

105 
115 
125 

127 
130 
131 
133 

147 
153 
154 
154 
155 
164 
166 
166 
168 
170 
170 
174 
174 
175 
175 
193 
193 
194 
194 
219 
223 
225 
291 
292 

293 
293 
295 

295 

295 


LIST  OF  ILLUSTRATIONS. 


FIG. 

45.  Kupture  of  zygote  cyst  into  the  body  cavity  of  the  mosquito  ;  free  sporo- 

zoites  (after  Grassi)     ......... 

46.  Parasite  of  quartan  malaria      ........ 

47.  Parasite  of  malignant  tertian  (aestivo-autumnal)  malaria 

48.  Amceba    coli ;    A.   dysenterioz  fixed    and    stained   (after    Councilman);    A 

chjsenterice  in  stools  (after  Losch)  ....... 

49.  Coccidium  oviforme,  from  the  liver  of  the  rabbit.     Stages  of  spore-formation 

only  observed  in  the  free  state  (after  Leuckart)     ..... 

50.  Eainey's  tubes,  x  about  40  diameters  ;  extremity  of  one  of  Miescher's  tubes 

with  its  contents.     At  the   side  are  the  kidney-shaped  bodies,  much 
enlarged  (after  Leuckart)     ......... 

51.  Monas  pyophila        ........... 

52.  Trichomonas  vaginalis  (after  Kolliker)         ....... 

53.  Lamblia  intestinalis  .......... 

54.  Balantidium    coli,    with    widely    opened    peristome,    dorsal    view    (after 

Leuckart)  ........... 

55.  Tapeworm  form  of  Tcenia  saginata  s.  mediocanellata  (after  Leuckart)     . 

56.  Apex  and  hooks  and  head  of  T.  solium  (after  Leuckart)       .... 

57.  Embryos  containing  egg  of  T.  solium  and  of  T.  nymphcea  (after  Leuckart)     . 

58.  The  common  bladder  worm  of  the  pig  with  invaginated  head  ;  the  same 

with  evaginated  head  (after  Leuckart) ....... 

59.  Head  of  T.  saginata  in  contracted  and  extended  condition  (after  Leuckart)  . 

60.  Cysticercus  tceniai  saginatce,  embedded  in  the  muscle  (after  Leuckart) 

61.  Measly  pork  (after  Leuckart)    ...... 

62.  Bothriocephalus  latus  (after  Leuckart) 

63.  Club-shaped  head  of  B.  latus  (after  Leuckart)     . 

64.  Ovum  of  B.  latus,  with  yoke  cells  and  shell  (after  Leuckart) 

65.  Larva?  of  B.  latus  from  the  pike  (after  Leuckart) 

66.  T.  nana  (after  Leuckart)  ....... 

67.  Distomum  hepaticum         .  ..... 

68.  Bedice  (after  Leuckart)     .  ..... 

39.  D.  sinense        ...  j  > 

70.  D.  luski 

71.  D.  ringeri  (after  Leuckart)         ...... 

72.  Ova  of  D.  ringeri  in  sputum     ...... 

73.  D.  haematobium,  male  and  female,  the  latter  in  the  canalis  gyneecophorus  of 

the  former  (after  Leuckart)  ..... 

74.  Ovum  and  free  embryo  of  Bilharzia  .... 

75.  Ascaris  lumbricoides,  female  (after  Leuckart) 

76.  Egg  from  A.  lumbricoides,  fresh  from  the  faeces  (after  Leuckart) 

77.  Oxyuris  vermicularis,  male  and  female  (after  Leuckart) 

78.  Eggs  of  0.  vermicularis  (after  Leuckart)     .... 

79.  Anhjlostomum  duodenale,  male  and  female  (after  Blanchard) 

80.  Male  A.  duodenale  ........ 

81.  A.  duodenale  (after  Sonsino)      ...... 

82.  Trichocephalus  dispar,  in  situ  (after  Leuckart) 

83.  T.  dispar  (after  Sonsino) ....... 

84.  Trichina  spiralis  (after  Leuckart)       ..... 

85.  Guinea- worm  (after  Leuckart) ...... 

86.  Embryos  of  guinea-worm  ...... 

87.  Filaria  loa  (after  Argyll  Robertson). 

88.  Embryo  Rhabdonema  intestinale  in  faeces  (after  Golgi  and  Monti) 

89.  Filaria  sanguinis  hominis  nocturna     ..... 

90.  „  „  ,,     perstans,  X  160     .... 
91—93.  Temperature  charts  in  simple  perityphlitis . 
94.  Temperature  chart  in  perityphlitic  abscess 


296 
299 
299 

527 

529 


530 
530 
531 
531 

531 
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532 
533 

533 

534 
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535 
535 
536 
536 
536 
537 
538 
539 
540 
540 
541 
541 

542 
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545 
545 
546 
546 
548 
548 
548 
550 
550 
551 
553 
554 
556 
557 
558 
561 
740 
741 


TEXT-BOOK    OF    MEDICINE. 


INTRODUCTION. 


THE   GENERAL   PATHOLOGY   OF   DISEASE. 

Without  a  knowledge  of  the  causation  and  the  processes  of  disease,  it  is 
impossible  to  appreciate  the  nature  and  symptoms  of  a  lesion.  The  physi- 
cian, in  making  his  diagnosis,  should  always  reflect  upon  the  changes, 
structural  and  functional,  which  might  lead  to  the  production  of  a  symptom, 
or  any  complex  of  symptoms.  A  knowledge  of  pathology  will  lead  him  not 
to  confound  the  symptom  with  the  disease,  either  in  diagnosis  or  in  treat- 
ment. Every  disease  has  a  cause.  It  may  be,  and  often  is,  easy  to  detect 
this  cause,  and  to  trace  the  relation  between  cause  and  effect,  but  obscure 
symptoms  may  be  due  to  changes  in  the  body,  of  which  those  unacquainted 
with  pathology  must  necessarily  remain  unaware.  Pathology  enables  the 
physician  to  determine  the  limits  and  mode  of  treatment,  and  also  the 
probable  or  possible  prognosis  of  a  case,  for  it  teaches  the  reactions  of  the 
body  and  its  tissues,  the  understanding  of  which  is  as  necessary  to  him  as 
is  a  familiarity  with  Euclid's  axioms  in  the  study  of  mathematics. 

A  student  working  in  the  wards  soon  learns  that  without  a  thorough 
knowledge  of  pathology  and  pathological  methods  a  sound  diagnosis  is  often 
impossible ;  he  finds  that  the  post-mortem  room  is  one  of  the  best  training 
schools  for  the  physician,  for  there  it  is  that  he  is  brought  face  to  face  with 
the  diagnosis  he  has  made,  that  imagination  is  controlled  by  fact,  and  that 
what  appeared  to  be  mysterious  and  inexplicable  finds  its  natural  explana- 
tion. Before  studying  disease  itself,  it  is  necessary  to  consider  generally 
but  carefully  the  processes,  causes,  effects,  and  concomitants  of  disease. 


THE  REACTIONS  OF  THE  BODY  AND  ITS  TISSUES. 

Degenerations,  inflammation,  and  repair,  hypertrophy  and  atrophy, 
are  the  most  essential  and  elementary  amongst  the  processes  of  disease. 
Of  these,  degenerations  and  atrophy  may  be  said  to  be  retrogressive  re- 
actions, through  which  the  functional  activity  of  an  organ  or' a  tissue  is 


2  GENERAL  PATHOLOGY  OF  DLSEASE. 

lowered;  inflammation,  repair,  and  hypertrophy,  on  the  other  hand,  are 
to  be  classed  as  progressive  reactions. 

Cloudy  Swelling. 

The  simplest  form  of  degeneration  is  the  so-called  cloudy  swelling, 
which  is  best  observed  in  the  renal  and  hepatic  epithelium  and  in  the 
heart  muscle.  The  organs  are  slightly  enlarged,  are  pale  and  cloudy  on 
section,  and  have  a  parboiled  appearance.  The  cells  or  fibres  swell  and 
assume  a  granular  and  cloudy  appearance,  their  nuclei  being  indistinct 
or  refusing  to  stain.  These  changes  are  observed  in  most  of  the  infections, 
e.g.  scarlet  fever,  diphtheria,  typhoid  fever,  septicaemia,  smallpox,  and 
erysipelas;  but  also  in  many  other  lesions  and  intoxicative  processes, 
such  as  acute  yellow  atrophy,  acute  Bright's  disease,  and  phosphorus 
poisoning,  and  are  the  expression  of  the  deleterious  action  of  certain 
toxic  substances  which  alter  the  albuminous  or  protoplasmic  constituents 
of  the  cells,  producing  a  kind  of  intracellular  coagulation.  The 
change  may  go  on  to  coagulative  necrosis,  the  cell  breaking  down  and 
being  completely  destroyed;  it  may  survive,  undergoing,  however,  fatty 
degeneration;  or  may  recover  completely.  Injury  to  the  cells  and 
insufficient  food  supply  are  also  common  causes  of  cloudy  swelling; 
thus  in  cardiac  disease  and  marasmus  the  renal  epithelium  becomes 
cloudy.  Inflammation,  whether  due  to  chemical,  physical,  or  bacterial 
agencies,  by  injuring  the  cell  directly  or  indirectly,  will  produce  cloudy 
swelling.  Virchow  believed  that  the  cloudy  swelling  in  the  early  acute 
Bright's  disease  was  the  evidence  of  increased  cellular  activity  on  the  part 
of  the  renal  cells,  and  this  he  regarded  as  the  sign  and  essence  of  the 
parenchymatous  inflammation,  wherefore  this  disease  has  been  called 
parenchymatous  nephritis.  It  is,  however,  held  by  some  that  cloudy 
swelling  is  a  sign  of  degeneration,  due  to  the  pressure  exerted  on  the  renal 
parenchyma  by  the  inflamed  interstitial  tissue  and  the  inadequate  nutri- 
tion of  the  cells,  resulting  from  the  stagnation  of  blood  in  the  inflamed  areas. 

Fatty  Changes. 

Fatty  changes  are  observed  in  the  tissues  and  organs  in  many 
diseases  and  under  the  most  varied  conditions.  Although  they  are  as 
a  rule  the  effect  of  a  general  lesion,  it  is  obvious  that  they  themselves 
must  produce  disturbances  and  impairment  of  function,  and  may  become 
the  starting-point  or  cause  of  other  lesions  and  morbid  states.  Before 
discussing  the  nature  of  fatty  changes,  it  will  be  advisable  shortly  to  state 
the  varieties  of  fatty  changes  as  they  are  usually  met  with  in  the  body. 

Accumulation. — An  increase  of  fat  may  take  place  in  situations 
where  it  normally  exists,  e.g.  (a)  in  the  panniculus  adiposus ;  (&)  in  the 
omental  tissues ;  (c)  in  the  epicardium ;  (d)  in  the  bone  marrow ;  and  (e) 
in  the  liver,  where,  at  certain  periods  after  the  ingestion  of  food,  fat  is 
always  found. 

Such,  accumulation  may  be — (1)  temporary  or  transient,  as  for  instance  in  the 
athlete  who  is  "  beefy  "  and  out  of  training — it  is  then  hardly  pathological ;  or  it 
may  be  (2)  permanent  and  lasting,  when  it  is  morbid.  Thus  in  obesity  or  lipo- 
matosis, there  is  always  a  considerable  storage  of  fat  in  the  subcutaneous  and 
omental  tissues,  and  the  liver  of  a  beer-drinker  is  generally  exceedingly  fatty. 
The  accumulation  obviously  must  be  due  to  one  of  two  processes,  or  probably  to  both 


FATTY  CHANGES  IN  TISSUES  3 

of  them.  Either  the  supply  of  fat-forming  material,  is  in  excess,  too  much  fat  being 
formed  by  the  cell ;  or  the  fat  formed  is  not  split  up  as  quickly  or  completely 
as  it  should  be,  owing  to  the  exhausted  condition  or  altered  nutrition  of  the  cells. 
It  is  evident  that  when  the  accumulation  is  excessive  or  too  persistent,  the  func- 
tions of  the  fat-laden  organ  or  tissues  may  gradually  become  impaired,  and  there- 
fore, if  the  causes  which  in  the  first  instance  led  to  the  fatty  changes  prevail,  the 
process  of  combustion  or  splitting  up  of  the  deposited  fat  will  also  be  interfered 
with ;  a  vicious  circle  is  thus  established.  Impairment  of  the  cell  function 
leads  to  fat  accumulation,  the  latter  increases  the  interference  with  the  cell  func- 
tion, and  so  on.  The  statement  that  the  accumulation  of  fat  is  due  either  to  over- 
production of  fat  or  to  failure  of  combustion,  or  to  both,  is  merely  a  suggestion  of 
what  is  obvious ;  it  is  no  explanation  of  the  process.  Why  should  fat  be  stored 
up  in  some  people  and  not  in  others  living  under  the  same  conditions,  why  should 
obesity  be  commoner  amongst  women  than  amongst  men  1  Some  people  "  run 
into  fat "  on  any  diet,  whatever  they  may  do  to  keep  their  flesh  down ;  others  it 
is  impossible  to  fatten. 

It  is  difficult  to  state  in  concise  and  definite  terms  the  causes  of  fat 
accumulation,  but  attention  must  be  drawn  to  some  leading,  or  it  may  be 
predisposing  factors.  Amongst  these  are — (a)  inherited  or  congenital 
tendencies ;  (b)  certain  habits  of  life,  such  as  indolence  and  sedentary 
occupations  ;  (c)  errors  of  diet ;  (d)  chronic  poisoning  {e.g.  alcohol) ;  (e)  sex, 
and  diseases  and  morbid  states  of  the  reproductive  organs  in  women  ;  (/) 
morbid  states  of  the  liver,  pancreas  (?),  or  thyroid  gland  (?). 

A  truly  morbid  accumulation  of  fat  is  progressive.  Any  exaggeration 
of  ordinary  physiological  conditions,  due  to  errors  in  living,  eating  and 
drinking,  may  be  set  right  again  by  correcting  these  errors. 

Encroachment. — An  extension  of  fat  into  tissues  which  normally 
are  free  from  it  may  occur — (a)  in  the  intermuscular  tissues  of  the  heart, 
spreading  thither  from  the  epicardial  fat ;  (b)  in  the  interstitial  tissue  of 
skeletal  muscle  (pseudo-hypertrophy) ;  and  (c)  in  the  endocardial  connect- 
ive tissues. 

In  the  fatty  heart  (lipomatosis)  of  an  obese  person  there  is  first  an 
accumulation  of  epicardial  fat,  whence  it  spreads  between  the  muscle 
fibres,  especially  of  the  right  ventricle,  often  reaching  the  connective 
tissue  under  the  endocardium. 

These  two  conditions  are  generally  included  under  the  single  term 
infiltration.  They  commonly  occur  together  in  the  same  organ,  and  in  the 
same  individual  they  may  affect  one  organ  alone,  or  all  the  organs  and 
tissues  capable  of  undergoing  fatty  changes.  Fat  accumulation  may  be 
so  localised  as  to  produce  a  distinct  tumour — a  lipoma.  In  all  these  con- 
ditions the  fat  is,  as  a  rule,  collected  in  the  cell  in  the  shape  of  large 
drops  or  droplets,  the  nucleus  being  pushed  to  one  side ;  the  cell  substance 
or  protoplasm  is  sound,  and  after  disappearance  of  the  fat  shows  no 
defects. 

Degeneration. — This  differs  from  fatty  accumulation,  in  which  the 
fat  is  formed  in  the  cell  and  stored  up  by  it,  in  so  far  that  the  fat  is  formed  at 
the  expense  of  the  cell  albumin.  Here  the  cell  substance  contains  globules 
or  numberless  small  granular  droplets  of  fat,  often  so  densely  packed  as  to 
hide  the  nucleus  or  obscure  the  structure  of  the  cell,  the  protoplasm  of 
which  is  destroyed;  on  dissolving  out  the  fat  the  cell  appears  vacuo- 
lated. Fatty  degeneration  is  therefore  a  destructive  process,  a  metabolic 
metamorphosis.  It  is  best  studied  in  the  cardiac  and  voluntary  muscles, 
in  the  liver  cells  and  renal  epithelium,  in  pus  cells,  and  in  nervous 
tissues. 


4  GENERAL  PA THOLOG  Y  OF  DISEASE. 

The  causes  of  fatty  degeneration  are  those  which  produce  serious  disturbance  of 
the  nutrition  or  vitality  of  the  cells.  Amongst  these  are — (a)  changes  in  the  blood 
and  nutriment  supplied  to  the  cells,  as,  for  instance,  in  diabetes  and  various  forms 
of  cachexia ;  (b)  vital  depression  and  asphyxia  of  the  tissues,  e.g.  venous  engorge- 
ment, inflammation,  pressure,  fever,  and  starvation  ;  (c)  local  and  general  anaemia, 
e.g.  haemorrhages,  leukaemia,  pernicious  anaemia,  and  carbon  monoxide  poisoning  ; 
(d)  intoxications,  which  include — (1)  Bacterial  intoxications  (infective  fevers,  such 
as  diphtheria,  pneumonia,  etc.)  ;  (2)  intoxications  by  inorganic  or  organic  chemical 
poisons,  such  as  phosphorus,  arsenic,  carbolic  acid,  corrosive  sublimate,  and 
alcohol ;  (3)  so-called  auto-intoxications  (e.g.  acute  yellow  atrophy) ;  (e)  nervous 
lesions,  which  may  lead  to  fatty  degeneration  in  the  muscles ;  (/)  disuse  of  the 
muscles  from  whatever  cause ;  (g)  fatty  accumulation  and  infiltration. 

The  extent  of  the  fatty  degeneration  varies  with  the  condition  producing  it. 
Thus  a  local  anaemia,  circumscribed  pressure,  or  a  focal  inflammation  can  only  pro- 
duce a  limited  area  of  degeneration.  Given  a  general  cause,  certain  organs  are 
more  predisposed  to  it  than  others,  as  for  instance  the  liver,  heart,  and  kidneys ; 
but  one  organ  may  be  affected  whilst  others  escape,  although  the  cause  be  a  general 
one.  Thus,  in  leukaemia,  the  heart  shows  the  fatty  degeneration  more  strikingly 
than  other  organs;  it  may  be  the  part  solely  affected.  In  a  single  organ,  the 
degeneration,  again,  may  be  general  or  local,  as  in  the  kidney. 

As  to  the  process  of  degeneration  in  the  cell,  our  knowledge  is  very  limited  ; 
Gau tier's  view  is  that,  under  physiological  conditions,  the  cell  passes  through  two 
phases — (a)  one  of  hydrolysis,  during  which  the  protoplasm  is  changed  into  urea 
and  its  allies,  and  the  carbohydrates  are  converted  into  fat.  This  is  followed  by 
(b)  the  second  phase  of  oxidation,  during  which  the  sugars  partly  disappear,  partly 
change  into  fat,  the  fats  eventually  being  burnt  up.  Imperfect  oxidation,  there- 
fore, would  produce  a  change  of  the  cell  protoplasm  into  fat.  Pavy,  who  holds- 
that  protoplasm  is  a  glucoside,  believes  that  through  some  ferment  action  the 
carbohydrate  molecule  of  the  proteid  is  converted  into  a  fat. 

Long-continued  or  excessive  fatty  accumulation  may  lead  to  fatty 
degeneration.  In  the  heart,  the  fat  which  has  extended  into  and  accumu- 
lated in  the  intermuscular  substance,  exerts  pressure  on  the  muscular 
fibres,  impairs  their  nutrition,  and  gives  rise  to  fatty  degeneration. 
Similarly,  a  liver  or  pancreas  heavy  with  accumulated  fat  eventually 
degenerates,  and  in  the  case  of  the  pancreas  the  glandular  substance  may 
disappear  altogether.  This  is  probably  due  to  two  factors — (a)  the  fat 
accumulation  reacts  deleteriously  on  the  vitality  of  the  higher  structures ; 
and  (b)  the  agent  which  produces  this  accumulation  is  often  a  tissue  poison 
(e.g.  alcohol),  which,  first  causing  an  accumulation  of  fat,  still  continues  to 
act  on  the  already  impaired  tissues,  and  so  advances  the  degeneration.  In 
the  same  way  the  continued  consumption  of  carbohydrates  must  be 
harmful  to  liver  cells  already  overloaded  with  fat. 

The  fatty  changes  in  the  more  important  tissues  or  organs  are  the 
following : — 

In  the  heart  there  is  (a)  an  increase  of  the  epicardial  fat,  which  may 
almost  surround  the  whole  heart ;  (b)  this  fat  may  spread  into  the  myocardium, 
along  the  intermuscular  tissue,  and  so  to  the  subendocardial  tissue ;  (c)  this 
accumulation  of  fat  may,  by  pressure,  cause  fatty  degeneration  of  muscular  fibres 
themselves ;  or  (d)  the  degeneration  of  the  myocardium  may  be  primary,  without 
any  previous  accumulation  of  fat  between  the  fibres.  It  is  then  generally  patchy, 
giving  rise  to  the  well-known  "tabby-cat"  striation,  "thrush's  breast"  or  "dead 
leaf"  appearance  often  so  well  marked  in  the  musculi  papillares.  Under  the 
microscope  the  degenerated  fibres  appear  granular,  and  innumerable  minute 
droplets  of  fat  take  the  place  of  the  striation. 


FATTY  CHANGES  IN  TISSUES.  5 

In  voluntary  muscles  the  changes  observed  are  analogous  to  those  met  with 
in  the  cardiac  muscle. 

In  the  kidney  the  fatty  changes  are  usually  purely  degenerative,  and  they 
generally  accompany  other  lesions,  such  as  so-called  parenchymatous  or  inter- 
stitial nephritis.  They  may  occur  independently — for  instance,  as  the  result  of 
phosphorus,  arsenic,  metallic,  or  carbolic  acid  poisoning,  or  as  the  result  of 
anaemia,  diabetes,  infective  fevers,  or  circulatory  disturbances.  They  may  be 
diffuse  or  focal,  and  in  either  case  are  generally  restricted  to  the  cortex.  "When 
focal — as  e.g.  in  diphtheria — the  looped  tubules  of  Henle  and  secondary  con- 
voluted tubules  are  affected ;  when  general,  the  degeneration  spreads  also  to  the 
large  convoluted  tubules,  the  Malpighian  bodies,  and  even  to  the  connective 
tissue.  The  fat  droplets  appear  first  in  the  part  of  the  cell  nearest  the  membrana 
propria  ;  they  then  gradually  invade  the  whole  cell,  and  eventually  the  cell  may 
break  down  completely  and  be  cast  off.  The  large  globules  of  fat  found  distend- 
ing the  cells  can  scarcely  be  of  this  nature. 

In  atheroma  of  the  aorta  the  branched  cells  of  the  intima  are  filled  with 
innumerable  droplets  of  fat,  the  nucleus  being  obscured,  although  itself  often 
not  degenerated. 

Fatty  changes  in  nerves  are  easily  recognised  in  the  so-called  peripheral 
neuritis.  The  myelin  sheath  1  breaks  up  into  globules  and  irregular  masses  of 
fat,  which  stain  intensely  black  with  osmic  acid,  and  analogous  changes  may  be 
observed  in  the  cord  in  cases  of  degeneration,  whether  ascending  or  descending. 

Next  to  the  heart,  fatty  changes  have  been  most  completely  studied  in  the 
liver.'2 

1  Normal  myelin  is  not  stained  black  with  Marchi's  fluid  (osmic  acid  solution  in  dilute 
Midler's  fluid),  although  ordinary  body  fat  (which  is  a  neutral  fat)  does.  The  myelin  has 
therefore  been  changed  into  fat. 

2  Kanthack  follows  Cohnheim,  and  does  not  use  the  term  infiltration.  He  says  :  ' '  The 
intestinal  epithelium  absorbs  fat  from  the  intestinal  contents,  and  leucocytes  and  phagocytes 
take  up  fat  granules  from  a  degenerated  area — these  are  the  nearest  approaches  to  an 
infiltration ;  it  is,  however,  an  ingestion,  followed  probably  by  assimilation  and  digestion. 
The  fat  appearing  in  the  tissues  under  normal  conditions,  whether  in  the  secreting  mammary 
gland,  in  the  liver,  or  in  the  panniculus  adiposus,  has  been  produced  by  chemical  action,  or  by 
a  fatty  metamorphosis  from  the  albuminous  cell  protoplasm ;  this  cannot  be  called  an 
infiltration.  In  fact,  the  physiological  secretion  of  milk  depends  on  a  true,  though  partial, 
fatty  degeneration  of  the  cells  lining  the  alveoli." 

' '  Pathologists  are  in  the  habit  of  distinguishing  between  fatty  infiltration  and  fatty  degener- 
ation in  the  liver  ;  their  criteria  are  partly  anatomical,  partly  morphological.  In  fatty  infil- 
tration the  globules  are  said  to  be  larger,  and  arranged  either  at  the  periphery  of  the  liver 
acini,  or  centrally  around  the  intra-acinous  vein,  or  in  the  interstitial  tissue  between  the  acini ; 
while  in  degeneration  the  droplets  are  said  to  be  small,  to  occupy  the  whole  cell,  and  the  meta- 
morphosis is  stated  to  be,  as  a  rule,  general.  It  is  asserted  that  in  the  former  case  the  fat  has 
been  stored  up  in  the  cell ;  in  the  latter,  it  has  been  formed  at  the  expense  of  the  cell  sub- 
stance. Most  observers  describe  infiltration  in  obesity,  nutmeg  liver,  phthisis,  cirrhosis,  and 
similar  conditions  on  account  of  the  anatomical  distribution  and  morphological  appearances  of 
the  fat.  In  obesity,  at  least  in  the  early  stages,  there  may  possibly  be  an  accumulation  of  fat 
without  the  cell  suffering,  the  cell  being  over-active,  and  forming  fat  from  the  material  generally 
supplied  in  excess ;  but  it  is  difficult  to  understand  how  a  true  accumulation  or  infiltration 
could  occur  in  diseases  in  which  the  fat  disappears  from  the  subcutaneous  and  omental  tissues, 
i.e.  in  wasting  diseases.  In  them  the  fat  must  have  been  formed  in  the  cell,  and  at  the 
expense  of  the  cell,  whether  the  appearances  are  those  of  infiltration  or  degeneration,  as  gener- 
ally desci'ibed.  In  the  obese  person  the  liver  cells,  after  forming  an  excess  of  fat,  are  capable 
of  replacing  the  cell  albumin  which  has  been  used  up  in  the  manufacture  of  fat,  and  only 
when  they  cease  to  do  this  will  degeneration  also  appear.  As  Cohnheim  puts  it,  the  guiding 
rule  of  distinction  between  degeneration  aud  infiltration,  or,  as  I  prefer  to  say,  accumulation, 
is  this  :  'Does  the  fat  occupy  a  cell  with  diminished  or  normal  albuminous  contents?'  In 
the  early  stages  of  obesity  there  is  merely  an  accumulation  of  fat  in  the  'legitimate  local- 
ities ' ;  in  the  later  stages  this  becomes  excessive,  and  the  fat  extends  beyond  these  localities, 
and,  as  far  as  the  liver  is  concerned,  instead  of  being  restricted  to  the  periphery  of  the  lobule, 
occupies  the  whole  of  it,  producing  a  large,  fatty  liver."  The  accumulation  of  fat  in  this  case 
is  probably  due  to  the  two  factors  mentioned  previously,  namely,  incomplete  oxidation  and 
excessive  supply  of  the  precursors  of  fat ;  it  is  not,  to  begin  with,  an  atrophy,  although  eventu- 
ally this  also  may  follow  in  some  of  the  organs  {e.g.  heart  and  liver).  He  agrees  with  Cohn- 
heim that  the  fatty  changes  observed  in  the  liver  with  anaemia,  phthisis,  cancer,  etc.,  are  all 


6  GENERAL  PATHOLOGY  OE  DLSEASE. 

The  true  accumulations — or  infiltrations,  to  use  the  more  familiar  term 
— are — (a)  the  normal  physiological  storage  of  fat;  (b)  the  transient 
accumulation  in  persons  of  sedentary  habits ;  and  (c)  all  but  the  most 
advanced  stages  of  obesity.  Other  conditions  are  atrophic,  and  are  asso- 
ciated with  fatty  degeneration.  There  are  undoubtedly  two  varieties  of 
fatty  degeneration.  In  one  the  destruction  or  disintegration  of  the  cell 
albumin  is  rapid  and  excessive,  and  the  cells  break  down  quickly,  as  for 
instance  in  acute  yellow  atrophy,  phosphorus  and  arsenic  poisoning;  in 
the  other  the  cell  destruction  goes  on  more  slowly,  and  the  fat  formed  at 
the  expense  of  the  cell  substance  has  a  chance  of  accumulating  for  a  long 
time  (e.g.  phthisis,  ansemia,  cachexia).  Local  fatty  changes  in  the  liver  are 
also  atrophic,  and  may  be  produced  by  pressure  of  tumours,  or  by  the  con- 
traction of  newly  formed  fibrous  tissue. 

Termination. — An  accumulation  may  either  disappear  by  oxidation 
and  resorption  on  change  of  habits,  or  it  may  pass  on  to  degeneration. 
Degeneration,  especially  if  local,  may  be  repaired  by  restitution  of  the 
tissues  (e.g.  in  muscles  and  nerves),  the  fat  granules  being  removed  by 
phagocytosis  or  oxidation ;  or  it  may  end  in  complete  disintegration, 
death,  and  necrosis,  the  fat  then  being  replaced  by  fibrous  tissue,  e.g. 
sclerosis  of  voluntary  muscle  or  of  the  nervous  tracts  in  the  cord,  in 
accordance  with  the  law  that  "  degenerate  tissue,  if  not  regenerated,  is 
replaced  by  connective  or  fibrous  tissue." 

Amyloid  Changes. 

In  amyloid  disease  curious  deposits  make  their  appearance  in 
certain  tissue  elements.  When  these  are  extensive,  they  are  not  unlike 
boiled  starch,  and  the  tissues  are  transformed  into  glassy  or  hyaline 
masses.  Amyloid  deposits  can  be  readily  demonstrated  by  the  following 
chemical  reactions : — (a)  A  solution  of  iodine  stains  amyloid  a  deep 
mahogany-brown;  if  a  weak  solution  of  iodine  be  allowed  to  act  for 
a  long  period,  and  sulphuric  acid  be  added,  a  bluish  or  violet  colour 
may  sometimes  be  obtained.  From  this  modified  starch  reaction  the 
name  "amyloid"  was  derived.  (b)  Methyl- violet  stains  the  amyloid 
material  red,  leaving  the  other  parts  bluish.  The  reaction  is  best  marked 
if,  after  staining  with  methyl-  or  gentian-violet,  the  tissues  be  washed  in 
water,  acidulated  with  hydrochloric,  oxalic,  or  acetic  acid.  It  must  be 
remembered  that  other  substances,  such  as  "  colloid  "  and  "  hyaline,"  occa- 
sionally stain  somewhat  like  amyloid ;  everything  that  gives  a  reel  reaction 
with  methyl-violet  must  not  be  regarded  as  amyloid.  According  to  Lubarsch, 
the  methyl-violet  test  is  convincing  (a)  wherever  iodine  or  iodine-sulphuric 
acid  gives  a  positive  reaction ;  (b)  in  the  absence  of  the  iodine  or  iodine- 
sulphuric  acid  reaction  wherever  the  substances  which  stain  red  with 
methyl- violet  optically,  chemically,  and  topographically  agree  with  genuine 
amyloid ;  or  (c)  wherever  it  appears  under  conditions  which  are  generally 
associated  with  amyloid  degeneration. 

true  fatty  atrophies,  whatever  they  may  appear  to  he  on  histological  rules,  more  or  less  arbi- 
trarily laid  down.  "In  phthisis,"  Kanthack  continues,  "the  fat  is  often  found  in  large  drops 
at  the  periphery  of  the  hepatic  lobule,  and  many  describe  this  as  infiltration  or  accumulation 
without  degeneration.  They  believe  that  the  excessively  fatty  liver  of  emaciated  con- 
sumptives is  due  to  an  infiltration  with  fat,  which  has  been  formed  elsewhere  during  the 
process  of  wasting.  How  can  this  be?  The  fat  must  have  been  formed  at  the  expense  of  the 
cell  substance,  and  it  remains  in  situ  on  account  of  diminished  combustion.  The  fatty 
changes  of  starvation  are  also  certainly  atrophic." 


AMYLOID  CHANGES.  7 

Amyloid,  though  a  proteid,  does  not  react  like  an  ordinary  albumin, 
and  resists  digestion.  It  is  asserted,  however,  that  in  a  finely  divided 
condition  it  undergoes  both  peptic  and  tryptic  digestion ;  it  is  dissolved 
on  heating  in  water  or  alkalies. 

Causation. — (1)  The  commonest  cause  is  chronic  suppuration,  and 
especially  that  accompanying  chronic  pulmonary  phthisis,  tuberculous 
disease  of  the  bones  and  joints,  syphilitic  bone  disease ;  ulcerating  cancers 
and  varicose  ulcers  of  the  legs  are  also  given  as  causes ;  (2)  tuberculosis 
and  syphilis  (especially  in  the  tertiary  or  congenital  form)  without  con- 
comitant suppuration ;  (3)  actinomycosis ;  (4)  Bright's  disease ;  and  (5) 
various  forms  of  grave  anaemia  and  cachexia  may  also  lead  to  amyloid 
disease.1 

If  the  various  lesions  with  which  amyloid  changes  may  occur  he  reviewed, 
it  will  be  found  that  the  common  factors  are — (1)  continued  loss  of  albumin,  pro- 
ducing chronic  anaemia,  or  marked  hydrsernia ;  and  (2)  the  incidence  or  inter- 
currence  of  infective  processes,  often  secondary,  such  as  suppuration  of  bone,  or 
in  connection  with  ulceration. 

Localisation. — In  general  amyloid  disease,  certain  organs,  the  liver,  spleen 
(of tener  than  any  other  organ),  kidney,  suprarenal  capsules,  lymphatic  glands,  and 
intestinal  mucosa,  especially  that  of  the  large  intestine,  are  more  especially  selected, 
and,  as  a  rule,  several  of  them  are  simultaneously  affected.2 

Most  of  the  attempts  to  produce  amyloid  disease  experimentally  have  been 
negative,  but  a  few  positive  results  have  been  recorded.  Czerny  kept  up  a 
chronic  suppuration  in  dogs  by  means  of  turpentine  and  nitrate  of  silver  injec- 
tions, and  found  that  the  spleen  and  liver  invariably  showed  amyloid  changes. 
Examining  the  pus  corpuscles  and  leucocytes,  he  found  that  during  the  experi- 
ments they  showed  granules  which  stained  dark  brown  with  iodine,  and  turned 
blue  on  the  addition  of  sulphuric  acid ;  he  assumes  that  this  substance  is  pre- 
amyloid  matter,  which  is  carried  by  the  leucocytes  to  the  tissues,  deposited 
there,  and  then  changed  into  amyloid.     Similarly,  he  found  that  during  suppur- 


1  In  269  cases  Birch-Hirschfeld  found  amyloid  changes — 

Times 
In  spleen  alone  .......  35 

,,  liver        ,,  ........  2 

,,  kidneys  „  .  .  .  .  .  .  1 

,,  spleen,  liver,  and  kidneys  ......         142 

,,  spleen  and  kidney  .  .      -       .  .  .  .  .77 

,,  spleen  and  liver       .......  10 

,,  kidneys  and  liver    .......  2 

2  Birch -Hirsclifeld  has  analysed  262  cases,  and  in  these  there  were  present — 


1.  Chronic  tuberculous  disease  of  the  lungs   . 

2.  Pulmonary  phthisis  and  bony  tuberculosis 

3.  ,,  ,,    intestinal  tuberculosis 

4.  ,,  ,,    syphilis    . 

5.  Bony  tuberculosis  alone 

6.  Chronic  suppuration  of  bone  (non -tuberculous) 

7.  Syphilis  (gummatous,  especially  in  liver)  . 

8.  Cancerous  ulcers     .... 

9.  Varicose  ulcers  of  leg 

10.  Visceral  suppuration 

11.  Actinomycosis 

12.  Noma     ' 

13.  Peritoneal  tuberculosis 

14.  Chronic  arthritis     .... 

15.  Suppurative  cystitis  and  pyelitis    . 

16.  Doubtful  causes       .... 


Times. 

140 

21 

18 

2 
28 

4 
15 

5 

3 

8 

1 

1 

4 

1 

1 
10 


262 


8  GENERAL  PATHOLOGY  OF  DISEASE. 

ative  processes  in  man  pre-amyloid  substances  appear  in  the  leucocytes,  and  lie 
concludes  that  the  precursors  of  amyloid  are  formed  in  the  pus — whether  micro- 
organisms are  present  or  not  is  immaterial ;  that  they  are  diffused  or  distributed 
in  the  various  organs  and  deposited  there  as  true  amyloid ;  and  that  this  deposi- 
tion shows  itself  first  in  the  spleen. 

Krakow  made  repeated  inoculations  into  rabbits  and  other  animals  with  pure 
cultures  of  the  Staphylococcus  pyogenes  aureus  until  they  showed  marked 
wasting;  he  thus  produced  amyloid  changes  in  their  organs,  which  also  began 
in  the  spleen,  and  in  every  detail  agreed  with  what  is  observed  in  man, 
microscopically  and  histologically.  He  believes  that  microbic  infection  is 
absolutely  necessary.  Other  observers  have  failed  to  obtain  results  similar 
to  those  obtained  by  Czerny  and  Krakow. 

Processes. — How  is  the  amyloid  substance  deposited  in  the  tissues? 
There  exist  two  conflicting  views — (1)  that  the  amyloid  is  produced  in  situ  by  the 
cells  from  their  albuminous  constituents — degeneration  ;  (2)  that  it  is  formed  in 
the  blood  and  carried  to  the  tissues — infiltration.  It  is  generally  accepted  that 
amyloid  matter  appears  in  the  interstitial  tissue  only,  never  in  epithelial  cells, 
although  such  excellent  observers  as  Dickinson  and  v.  Kecklinghausen  spoke,  and 
the  latter  still  speaks,  of  intercellular  and  intracellular  infiltration.  Most  patho- 
logists hold  that  it  is  exclusively  the  connective  tissue  which  contains  the  amyloid, 
whether  it  be  deposited  there  by  a  process  of  degeneration  or  by  infiltration.  If 
Czerny's  observations  be  accepted,  the  amyloid  change  is  an  infiltration.  Against 
this  is  the  fact  that  amyloid  has  never  been  observed  in  the  blood.  It  is  un- 
doubted that  amyloid  appears  first  in  the  intercellular  substance.  It  has  been 
stated  by  some  observers  that  in  the  liver  the  amyloid  is  deposited  first  in  the 
hepatic  cells  (Dickinson) ;  but  others,  and  especially  more  recent  observers,  em- 
phatically deny  that  these  cells  ever  show  amyloid  changes,  and  that  amyloid 
changes  ever  occur  in  (a)  epithelium,  (b)  striped  or  unstriped  muscular  tissue,  or 
(c)  leucocytes,  but  that  the  deposition  is  always  an  interstitial  one,  and  that  the 
tissue  cells  degenerate  through  pressure  exerted  by  the  amyloid  tracts. 

Amyloid  changes  during  the  earliest  stages  are  most  frequently 
observed  in  or  along  the  capillaries  and  smallest  arterioles.  Their  walls 
become  swollen,  and  their  lumen  narrowed ;  in  the  arterioles  the  amyloid 
matter  is  deposited  in  the  middle  coat,  the  muscular  elements  remaining 
intact,  the  material  appearing  in  the  connective  tissue ;  in  the  capillaries 
it  is  deposited  in  the  interstitial  substance  of  their  walls.  From  these 
points  the  amyloid  change  extends  into  the  surrounding  tissues,  impli- 
cating the  connective  tissue  and  the  basement  membranes.  In  the  liver 
and  kidney  the  epithelial  cells  outside  the  amyloid  tracts  alway  show 
marked  fatty  degeneration,  and  those  within  these  tracts  disappear  alto- 
gether ;  and  when  vital  organs  are  concerned,  the  final  results  must  be 
anaemia,  hydremia,  marasmus,  and  death.  The.  amyloid  matter  not  only 
presses  on  the  cells,  but  also  narrows  the  lumina  of  the  vessels ;  vascular 
obstruction  is  produced,  which,  if  arterial,  still  further  impairs  nutrition 
and  function ;  and,  if  venous,  may  lead  to  oedema  and  dropsy.  Thus, 
in  amyloid  disease  of  the  liver,  ascites,  due  to  portal  obstruction,  is 
common ;  in  amyloid  disease  of  the  kidney,  albuminuria  not  unfrequently 
occurs. 

Terminations. — Is  amyloid  substance,  once  formed,  ever  reabsorbed  ? 
Litten  attempted  to  answer  this  question  experimentally  by  placing  frag- 
ments of  amyloid  tissue  in  the  peritoneal  cavity  of  the  rabbit ;  what  was 
left  of  the  amyloid  tissue  no  longer  gave  the  methyl- violet  reaction.  It  is* 
known  that  wandering  cells  may  ingest  amyloid  matter.  There  is  some 
clinical  evidence  that  occasionally  an  amyloid  liver  may  diminish  in  size. 


HYALINE  AND   WAXY  DEGENERATION  9 

'It  must,  however,  be  remembered  that  the  clinical  diagnosis  is  by  no  means 
always  certain. 

In  the  liver  the  amyloid  is  early  deposited  along  the  capillary  walls  in  the 
intermediate  or  hepatic  zone  of  a  few  lobules,  compressing  the  liver  cells,  which 
themselves,  however,  remain  otherwise  unaffected,  and  the  naked-eye  appearances 
are  almost  unchanged ;  later,  the  liver  becomes  enlarged  and  firm,  smooth,  and 
almost  opalescent  on  section.  The  degeneration  affects  specially  the  intermediate 
portions  of  the  acini.  Such  as  are  left  of  the  liver  cells  must  be  looked  for  at  the 
extreme  periphery  or  the  extreme  centre  of  the  lobule ;  those  at  the  periphery 
are  almost  always  in  a  state  of  fatty  degeneration.  In  the  amyloid  zone  nothing 
is  found  of  the  cell  outlines  ;  the  cells  have  vanished,  or  only  the  merest  remnants 
are  found. 

(a)  In  diffuse  amyloid  spleen,  usually  associated  with  heart  disease,  the 
sinuses  and  capillaries  are  surrounded  by  amyloid  tracts,  which  also  extend  along 
the  reticulum,  gradually  compressing  the  spleen  cells,  and  pressing  upon  the 
follicles,  which  are  unaffected  excejDt  in  many  cases  as  to  the  central  vessel. 

(b)  In  sago  amyloid  spleen,  the  capillaries  and  reticulum  of  the  follicles  become 
amyloid ;  the  lymphocytes  eventually  may  disappear  altogether  through  pressure. 
The  central  vessel  is  seldom  affected,  and  then  at  a  late  stage  of  the  disease. 

In  the  kidneys  the  amyloid  changes  are  best  observed  in  the  cortex,  but 
are  present  also  in  the  medulla.  In  the  cortex,  the  glomeruli,  merubranse  pro- 
prise,  arteries,  and  capillaries  are  affected,  and  in  the  medulla  the  vessel  walls 
and  rnembranse  propriae,  but,  as  stated  by  modern  observers,  the  renal  epithelium 
seldom  or  never  suffers.  The  glomeruli  become  enlarged  and  transparent,  and 
filled  by  amyloid  capillary  loops ;  the  nuclei  of  the  glomerular  epithelium 
disappear. 

Intestine. — The  amyloid  changes  are  observed  in  the  walls  of  the  vessels  of 
the  villi,  mucosa,  and  submucosa,  and  in  the  reticulum  of  the  villi. 

Lymphatic  glands. — The  capillaries  and  reticulum  become  amyloid,  and 
appearances  resembling  those  described  in  the  spleen  are  seen. 

Occasionally  amyloid  changes  may  appear  locally,  as  in  the  conjunctiva  and 
in  the  connective  tissue,  or  in  tumours.  These  require  no  special  description  or 
discussion. 

Hyaline  and  Waxy  Degenekation. 

Under  certain  conditions  hyaline  masses,  transparent,  homogeneous,  and 
bright  in  appearance,  are  met  with  in  the  organs  and  tissues.  Hyaline  is  not 
a  definite  chemical  substance,  but  includes  bodies  all  of  which  are  charac- 
terised by  their  great  resistance  to  water,  alcohol,  acids,  and  ammonia,  and 
their  affinity  for  acid  aniline  dyes,  such  as  acid-fuchsin  and  eosin;  von 
Eecklinghausen  includes  hyaline,  mucous,  and  amyloid  changes  under  colloid 
metamorphosis,  but  this  is  misleading.  Klebs  restricts  the  terms  colloid  to 
all  hyaline  substances  derived  from  epithelium  and  hyaline  to  similar 
substances  derived  from  connective  tissue;  this  seems  to  be  the  safest 
classification,  although  it  indicates  but  roughly  the  chemistry  of  these 
bodies. 

Certain  authors  maintain  that  there  are  two  varieties  of  hyaline — (a) 
that  secreted  by  the  connective  tissue  cells  (i.e.  of  intracellular  origin) ;  and 
(b)  that  produced  by  coagulation  of  plasmatic  fluids,  serum,  plasma,  or 
lymph  (i.e.  of  extracellular  origin).  It  is  best  to  agree  with  Birch- 
Hirschfeld  that  intracellular  hyaline  formation  is  merely  a  form  of  so- 
called  coagulation  necrosis,  and  that  hyaline  degeneration  is  due  to  a 
coagulation  of  fluid  derived  from  the  blood  plasma,  muscle  plasma,  lymph 
or  cell  plasma. 


io  GENERAL  PATHOLOGY  OF  DISEASE. 

Hyaline  changes  may  be  hematogenous,  as  in  thrombi  in  the 
capillaries,  especially  in  infective  diseases;  or  exudative,  when  a  diph- 
theritic membrane  becomes  hyaline ;  or  when,  in  chronic  Bright's  disease, 
the  albuminous  casts  become  hyaline.  The  muscle  substance  in  some 
cases,  especially  in  infective  fevers  {e.g.  typhoid  and  diphtheria)  may 
break  up  into  hyaline  transparent  masses,  no  doubt  due  to  a  coagulative 
change  in  the  muscle  plasma.  This  condition  is  frequently  spoken  of 
as  vitreous  degeneration,  and  may  be  caused  also  by  injury,  chemical, 
physical,  or  mechanical,  to  the  muscle.  The  fibres  break  up  inside  the 
sarcolemma  into  irregular  hyaline  masses  which  swell,  and  as  a  rule  are 
broader  than  the  unchanged  fibres.  On  microscopic  examination  the 
muscle  has  a  cloudy  or  boiled  appearance.  Fibrin,  which  itself  is  a 
product  of  coagulation,  may  become  hyaline,  as  frequently  observed  in 
croupous  pneumonia,  in  thrombi,  and  in  the  walls  of  aneurysms. 

Hyaline  changes  must  be  regarded  as  the  result  of  coagulative  processes,  all 
the  more  that  they  are  generally  observed  in  inflammatory  lesions,  or  where  there 
has  been  an  increased  exudation.  The  vessel  wall  or  surrounding  connective 
tissue  or  muscle  substance  imbibes  some  kind  of  fluid  which  coagulates.  Some 
writers  believe  that  hyaline  is  closely  allied  to  amyloid,  because  hyaline  degenera- 
tion may  be  an  antecedent  condition ;  hyaline  and  amyloid  changes  are  often 
found  together,  and  there  is  a  gradation  in  staining  reactions  from  amyloid  to 
hyaline ;  hyaline  changes  are  common  in  and  around  the  capillary  or  arterial 
vessel  wall,  and  amyloid  changes  always  begin  there ;  lastly,  infective  processes 
are  common  causes  of  both  forms  of  degeneration. 


Colloid  Changes 

These  are  allied  to  mucous  and  hyaline  degeneration.  Colloid  differs  from 
mucin  in  that  it  is  not  precipitated  by  alcohol  and  acetic  acid.  It  is  a 
gelatinous  hyaline  substance  and  is  always  of  epithelial  origin.  Many  changes 
are  frequently  described  as  colloid  which  are  not  of  this  nature.  Physiologically 
colloid  appears  in  the  follicles  of  the  thyroid  gland,  and  if,  as  in  goitre,  the 
production  of  colloid  becomes  excessive,  the  condition  becomes  pathological..  In 
tumours  also  (carcinoma)  colloid  may  be  formed,  the  cells  becoming  distended 
with  globules  and  masses  of  colloid  which  they  discharge,  while  they  themselves 
may  be  entirely  destroyed.  It  is  doubtful,  however,  whether  the  so-called  colloid 
cancer  is  really  colloid,  and  not  rather  myxomatous.  In  interstitial  nephritis 
colloid  cysts  are  frequently  found,  though  some  writers  are  inclined  to  regard 
their  contents  as  produced  by  coagulation  of  an  albuminous  substance,  and 
therefore  as  being  allied  to  hyaline. 

Mucous  Changes. 

Mucin  is  a  transparent  viscid  colloid  substance,  the  chemical  nature  and 
properties  of  which  are  as  yet  insufficiently  known.  According  to  Landwehr, 
it  is  a  compound  of  albumin  with  a  carbohydrate  body  called  animal  gum, 
which  on  boiling  with  dilute  mineral  acids  (sulphuric  acid)  yields  a  non-fer- 
mentable sugar.  The  mucin  produced  by  epithelial  cells  differs  materially  from 
that  derived  from  connective  tissues,  whilst  again  the  mucin  obtained  from 
epithelium  is  not  a  constant  substance.  Thus  the  mucin  found  in  ovarian  cysts 
is  not  precipitated  by  acetic  acid,  while  that  formed  by  the  columnar  cells  of  the 
intestines  is  solidified  by  both  alcohol  and  acetic  acid. 

Under  pathological  conditions,  mucin  may  show  itself  (a)  as  a  product  of 
abnormal  epithelial  activity.  The  columnar  cells  of  mucous  membranes  normally 
form  mucin     in  a  mucous  catarrh  the    number  of  goblet  cells  becomes  much 


WASTING  AND  ATROPHY.  n 

increased,  or  every  columnar  cell  may  be  distended  with  mucin.  Again,  the 
columnar  cells  lining  the  cystic  spaces  of  an  innocent  tumour  (such  as  an 
ovarian  cyst),  or  of  a  malignant  tumour  (such  as  a  columnar-celled  carcinoma), 
may  also  produce  an  excessive  amount  of  mucin,  so  that  the  cystic  spaces 
become  distended  with  mucus.  On  the  other  hand,  (b)  mucin  may  appear  in 
connective  tissue,  bone,  cartilage,  and  fat,  or  in  the  connective  tissue  tumours. 
There  is  then  either  a  viscid  gelatinous  matrix,  embedded  in  which  are  numerous 
reticular  cells,  or  a  more  or  less  dense  network  of  filaments  (a  reticulum).  In 
myxcedema,  in  certain  stages  of  the  disease,  the  connective  tissue  of  the  skin 
becomes  gelatinous.  It  must  be  remembered  that  embryonic  connective  tissue 
is  myxomatous,  and  that,  therefore,  young  connective  tissue  appearing  under 
morbid  conditions  is  also  frequently  mucous. 

Wasting  and  Ateophy. 

Atrophy,  closely  allied  to  degeneration,  is  a  condition  in  which  there 
is  diminution  in  the  size  of  an  organ  or  part,  or  even  a  cell  of  the  body. 
This  is  a  purely  morphological  term,  and  was  originally  used  to  indicate 
macroscopic  changes.  When  a  liver  rapidly  decreased  in  volume,  as  the 
result  of  marked  fatty  degeneration,  the  process  was  called  an  acute 
atrophy ;  but  from  histological  observation  it  is  now  known  that  this  is 
a  degeneration  followed  or  accompanied  by  necrosis,  and  not  an  atrophy 
proper.  Arrested  development  (hypoplasia)  must  not  be  confused 
with  atrophy,  for  here  the  organ  has  never  attained  its  normal  size. 
Hypoplasia  may  be  due  to  intra-uterine  changes,  or  it  may  be  caused 
by  forces  acting  at  the  seat  of  and  during  the  period  of  growth,  as 
in  microcephalus,  undeveloped  thyroid,  and  stunted  epiphyses  of  long 
bones  following  rickets  or  inflammation.  After  an  amputation  of  a 
leg,  during  childhood  or  youth,  the  corresponding  side  of  the  pelvis 
remains  small,  whilst  infantile  paralysis  of  the  upper  extremity  leads 
to  arrested  development  of  the  clavicle  and  scapula  on  the  same 
side.  When  development  has  not  taken  place  at  all,  the  term  aplasia 
or  agenesis  is  used. 

Atrophy  of  an  organ  must  be  due  (1)  to  diminution  in  the  size  of 
the  component  elements,  (2)  to  a  diminution  in  the  number  of  these 
elements,  or  (3),  and  most  commonly,  to  a  combination  of  the  two.  At 
the  same  time,  inadequate  regeneration  may  play  a  most  important  part 
in  this  condition.  Under  physiological  conditions  cells  continually  dis- 
appear, but  they  are  replaced  by  others.  If,  however,  the  regener- 
ative process  does  not  at  least  balance  the  normal  decay,  the  part 
must  diminish  in  size,  i.e.,  it  must  undergo  atrophy,  as  when  tissues 
become  senile,  e.g.  the  skin  and  the  muscles  of  an  old  man  are  visibly 
atrophic,  although  there  is  no  degeneration ;  a  cell,  having  played  its  part, 
disappears  from  the  scene,  and  its  place  is  not  filled  by  another  cell, 
— simple  atrophy.  In  the  atrophy  of  degeneration,  on  the  other  hand,  the 
cells  become  fatty,  hyaline,  amyloid,  or  necrotic,  and  are  then  removed  as 
dead  matter  or  are  replaced  by  fibrous  tissue ;  the  part  becomes  smaller  and 
many  cells  disappear,  the  diminution  being  due  to  degeneration  and 
death,  and  the  removal  of  the  useless  material.  It  may  be  held  that  as 
decayed  tissue  is  replaced  by  fibrous  tissue,  which,  contracting  still 
further,  diminishes  the  size  of  the  organ,  it  is  quite  unjustifiable  to  speak 
of  atrophy.  The  shrinkage  in  an  atrophic  cirrhosis  of  the  liver,  or  an 
atrophic  red  kidney,  is  due  to  the  condensation  of  the  fibrous  tissue,  and 
it  might  be  better  to  speak  of  a  shrinking  liver,  and  a  shrinking  or 


1 2  GENERAL  PA  THOL O GY  OF  DISEASE. 

contracting  kidney.  On  examining  such  a  shrinking  organ,  e.g.  kidney, 
it  will  be  found  that  many  of  the  epithelial  cells  pressed  upon  by  the 
fibrous  tissue  become  smaller  and  smaller,  i.e.,  they  atrophy,  till  eventually 
they  degenerate,  die,  and  are  cast  off.1 

Simple  atrophy  may  be  observed — (1)  under  physiological  conditions,  e.g., 
when  the  thymus  gland  gradually  disappears  ;  (2)  as  a  senile  change  ;  or  (3)  it  may 
be  due  to  morbid  conditions,  e.g.,  when,  on  account  of  diminished  nutrition,  an  organ 
or  a  tissue  becomes  reduced  in  size.  Thus  during  inanition  the  fat  atrophies,  the 
muscle  becomes  smaller,  and  the  glandular  cells  disappear,  there  being  in  all  three 
cases  an  impairment  of  regeneration  on  account  of  the  inadequate  food  supply. 
It  is  doubtful  whether  the  disappearance  of  the  fat  can  be  called  an  atrophy, 
except  in  the  sense  that  it  is  not  regenerated.  Just  as  the  plant  stores  up  starch 
for  future  consumption,  so  does  the  animal  body  store  up  fat ;  the  using  up  of 
the  fat  is  not  atrophy,  but  the  adipose  cushions  vanish,  because  there  is  no 
regeneration.  The  diminution  of  nutrition  may  be  due  (a)  to  general  causes, 
such  as  starvation,  or  (b)  to  local  circulatory  disturbances  or  local  pressure, 
but  in  the  latter  case  there  is  also,  as  a  rule,  actual  destruction  of  the  cells  by 
continued  pressure. 

In  morbid  conditions  "  simple "  atrophy  is  rarely  met  with.  When  a 
paralysed  muscle  wastes,  it  generally  becomes  fatty,  or  is  replaced  by  fibrous  or 
fatty  tissue,  and  similarly  in  starvation  the  cells  in  the  wasting  organs  often 
undergo  degeneration.  Indeed,  true  and  uncomplicated  histological  atrophy  is 
rare ;  either  degeneration  or  fibrosis  is  also  present,  or  the  two  processes  may  be 
combined.  Atrophy,  in  the  generally  accepted  sense  of  the  term,  is  usually 
accompanied  or  preceded  by  degeneration,  and  may  be  due  to  shrinkage  of 
newly  formed  tissue. 

Atrophied  tissue  may  be  restored,  as  where  a  wasted  muscle  again  increases 
in  bulk ;  in  which  case  an  active  regeneration  more  than  balances  the  normal 
loss.  But  if  repair  does  not  take  place,  then  the  muscle  degenerates  or  dies ; 
should  "  repair  "  occur  after  this,  as  it  may,  it  must  be  either  by  new  proliferation 
of  homologous  cells,  or  by  the  formation  of  fibrous  tissue.  (See  "Chronic 
Inflammation.") 

Necrosis  and  Necrobiosis. 

Death  of  the  tissues  may  be — (a)  Gradual  (necrobiosis),  when  it  is 
usually  preceded  by  a  chronic  degeneration,  such  as  fatty  degenera- 
tion or  a  more  acute  form  of  degeneration,  such  as  cloudy,  hyaline, 
or  coagulative  changes,  nothing  of  the  original  shape,  form,  or  struc- 
ture of  the  tissue  being  left.  In  tuberculosis  and  syphilis,  and  even  in 
carcinoma  and  sarcoma,  it  is  generally  maintained  that  a  process  of  so- 
called  coagulative  necrosis,  which  is  closely  allied  to  cloudy  swelling 
and  to  the  hyaline  or  waxy  changes,  is  first  set  up.  The  cell  pro- 
toplasm becomes  solid  or  coagulated,  granular  or  hyaline,  the  nucleus 
disappears  or  becomes  obscured,  and  both  cell  and  nucleus  refuse  to 
stain.  If  this  intracellular  coagulation  is  followed  by  a  breaking  up  of 
the  cell  into  detritus  or  fatty  debris,  then  the  result  may  be  caseation. 
Caseation,  however,  is  quite  independent  of  fatty  metamorphosis,  and 
may  occur  without  it.  Caseous  matter,  as  a  rule,  is  semi-solid  or 
pultaceous,  whitish  or  yellowish  in  colour,  microscopically  granular, 
staining  indefinitely,  or  not  at  all  (in  certain  stages  of  the  process 
hematoxylin   gives   a   very   deep   stain) ;    it   becomes   dry   and   cheesy ; 

1  Kanthack  held  that  in  a  shrinking  organ,  cellular  atrophy  may  be  observed  under  the 
microscope,  but  that  the  shrinkage  is  not  atrophy.  It  is  well  to  remember,  however,  that 
atrophy  is  a  mixed  process,  and  received  its  name  before  pathological  histology  existed. 


NECROSIS  AND  NECROBIOSIS.  13 

it  is  dead  matter,  and  therefore  becomes  easily  calcified,  and  if  present 
in  any  quantity  cannot  be  absorbed,  but  must  be  removed,  either  by 
operation  or  by  ulceration. 

Death  of  the  tissues,  on  the  other  hand,  may  be — (b)  Acute  or  sudden 
(necrosis),  the  tissues  retaining  their  form  for  some  time,  and  must  be  the 
result  of  either  (1)  a  gross  or  fatal  tissue  injury,  or  (2)  starvation  of  the 
tissues,  due  either  to  want  of  food  or  incapacity  on  the  part  of  the  cells 
to  assimilate  the  food  supplied.  Thus  a  direct  injury,  e.g.  a  crush,  a  burn, 
or  a  caustic,  may  destroy  cell  life  immediately,  or  it  may  lead  to  serious 
inflammation,  which  only  later  brings  about  the  death  of  the  part.  Again, 
if  the  nutrition  of  the  cell  is  suspended  it  must  die,  as  when  there  is  a 
complete  or  serious  obstruction  to  the  circulation,  (1)  arterial,  (2)  venous, 
or  (3)  capillary.  Thrombosis,  embolism,  or  obliterative  endarteritis  may 
produce  gangrene  or  necrosis,  e.g.  dry  gangrene  in  the  extremities, 
cerebral  softening,  infarctions.  Complete  venous  obstruction,  as  for 
instance  in  a  strangulated  hernia,  may  cause  absolute  stoppage  of  the 
circulation,  i.e.  capillary  stasis,  which,  if  not  relieved,  must  result  in  death 
of  the  part.  A  complete  capillary  stasis  may  also  be  produced  by 
inflammatory  pressure,  due  to  the  accumulation  of  exudation  ;  in  dense 
hard  tissues,  as  in  bone,  this  often  leads  to  necrosis. 

It  is  evident  that  an  injury  leads  to  necrosis  partly  by  favouring  or  producing 
inflammation,  which  in  its  turn  favours  capillary  stasis,  and  partly  by  impairing 
the  vitality  of  the  cells  directly,  so  that  comparatively  slight  causes  are  sufficient 
to  extinguish  life  altogether.  It  must  further  be  remembered  that  in  many 
forms  of  gangrenous  or  necrotic  inflammation,  such  as  diphtheria,  cellulitis, 
phagedena,  etc.,  bacteria  are  concerned ;  they  keep  up  a  continual  supply  of 
tissue  poisons,  which  not  only  have  a  deleterious  action  on  the  cells  themselves, 
but  also  excite  the  surrounding  tissues  to  inflammation.  A  vicious  circle  is  thus 
established;  the  bacterial  irritants  predisposing  or  weakening  the  tissues,  which 
then  succumb  readily  to  the  inflammatory  pressure,  which  latter  in  turn  predisposes 
the  tissues  to  the  action  of  the  bacterial  poisons.  Weakened  or  predisposed 
parts  become  necrosed  more  readily  than  vigorous  and  healthy  ones,  and  causes 
which  under  normal  conditions  would  only  produce  an  inflammation  or  a 
transient  retrogressive  change,  may  be  severe  enough  to  destroy  a  debilitated 
organ  or  group  of  cells.  Thus  an  incomplete  arterial  obstruction  may  cause 
gangrene  in  an  individual  suffering  from  cardiac  disease,  or  in  the  old  and 
exhausted  ;  necrosis  of  the  bone  is  commoner  in  those  who  suffer  from  infective 
fevers,  and  infective  emboli  are  more  serious  than  simple  ones.  Chronic 
alcoholism  predisposes  to  gangrenous  cellulitis ;  diabetes,  anaemia,  marasmus, 
general  weakness,  and  a  feeble  circulation  are  also  all  powerful  predisposing 
factors  ;  the  tissues  are  already  badly  nourished  under  such  conditions,  and  but 
little  suffices  to  destroy  life  altogether.  Sometimes  the  predisposing  factors  may 
be  local,  such  as  atrophy  or  serious  lesions.  Paralysis  and  anaesthesia  are  not 
direct  causes  of  necrosis,  but  they  favour  its  occurrence  no  doubt  by  influencing 
the  nutrition  of  the  part. 

Gangrene  and  necrosis,  therefore,  are  due  to  (a)  a  cutting  off  of 
nutrition  from  a  part,  (b)  changes  which  exclude  the  assimilation  of  what 
is  supplied,  (c)  predisposing  causes,  intensifying  the  effect  of  the  two  pro- 
cesses mentioned.  Generally  speaking,  it  may  be  said  that  the  first 
change  is  a  coagulation  of  the  protoplasmic  cell  contents,  i.e.  a  coagu- 
lative  necrosis.  If  no  moisture  is  supplied,  or  if  that  which  exists 
is  absorbed  or  evaporates,  the  result  is  a  dry  gangrene  or  mummifica- 
tion, but  if  the  part  is  moist  from  oedema,  whether  passive  or 
inflammatory,   then   a   moist  gangrene   or   colliquative    necrosis   results. 


1 4  GENERAL  PA THOL OGY  OF  DISEA SE. 

The  dead  or  dying  tissues  may  putrefy  if  bacteria  find  an  abode  in  them, 
and  these  bacteria  may  themselves  cause  a  liquefaction  of  the  decomposing 
matter. 

Thus  there  may  be  distinguished — (1)  dry  gangrene,  due  as  a  rule  to 
an  obstruction  or  weakness  of  the  arterial  circulation ;  (2)  moist  gangrene, 
which  is  due  either  to  the  same  causes,  oedema  existing  or  appearing  at 
the  same  time,  or  has  its  origin  in  a  severe  inflammatory  condition; 
(3)  traumatic  gangrene,  which  includes  (a)  immediate  death  as  the  result, 
for  instance,  of  a  crush,  or  (b)  inflammatory  necrosis  (cellulitis  and 
phagedena),  or  (c)  special  infective  forms,  such  as  noma,  cancrum  oris, 
acute  spreading  gangrene,  or  emphysematous  gangrene,  or  rapid  septic 
gangrene,  or  necrosis ;  (4)  symmetrical  or  idiopathic  gangrene,  the  etiology 
of  which  is  at  present  but  little  known;  (5)  gangrene  accompanying 
infective  fevers,  such  as  ulcerative  endocarditis,  typhoid  fever,  etc. ; 
(6)  the  gangrene  of  anaemia  and  marasmus ;  and  (7),  most  obscure  form 
of  all,  the  gangrene  of  nervous  origin,  e.g.  hysteria  and  Eaynaud's  disease. 
Any  form  of  ulceration,  or  sloughing  inflammation,  bedsore  after 
hemorrhagic  extravasations,  from  pressure  or  during  oedema,  or  abscess, 
is  accompanied  by  necrosis,  which,  however,  may  be  so  small  as  to  escape 
detection  with  the  naked  eye. 

In  bones  the  death  of  the  tissues  shows  itself  either  in  the  form  of  an  extensive 
necrosis, — a  sequestrum,  or  as  caries.  In  the  intestinal  tract,  gangrene  of  the  bowel 
is  observed  in  cases  of  hernia,  intussusception,  and  strangulation ;  necrosis  occurs 
in  the  various  forms  of  ulceration,  such  as  are  seen  in  typhoid  fever,  ulcerative 
colitis,  and  dysentery ;  while  in  the  pharynx  and  larynx,  diphtheria  offers  the 
commonest  example  of  necrosis.  In  the  lungs  large  areas  may  become  gangrenous, 
as  for  instance  during  or  after  pneumonia ;  or  as  the  result  of  the  presence  of  a 
foreign  body  or  an  injury.  Necrosis  is  observed  with  caseation  or  during  the 
development  of  cavities  in  the  lung.  Sloughing  and  necrosis  also  occur  in  new 
growths,  especially  in  those  of  a  malignant  type,  of  the  bladder  and  uterus,  liver 
and  pancreas.  The  so-called  fat  necrosis,  in  which  the  omental  and  mesenteric 
fat  more  especially  shows  numerous  dull  white  or  yellowish  areas,  consisting 
of  dead,  solid,  or  saponified  fat,  generally  accompanies  sloughing  or  inflammation 
of,  or  hsemorrhage  into,  the  pancreas. 

Necrosed  tissue  must  be  removed  from  the  body,  and  whatever  defect 
remains  is  subsequently  made  good  by  newly  formed  fibrous  tissue,  unless 
the  necrosis  was  slight  and  superficial,  when  there  may  be  homologous 
repair,  as  for  instance  when  epithelium  is  cast  off  and  the  gap  is  filled  by 
epithelium. 

Calcification  and  Concretions. 

Calcareous  changes  generally  appear  in  dead  or  dying  tissues,  never 
in  perfectly  sound  and  normal  structures.  Two  main  processes  may  be 
distinguished — (a)  infiltration  and  (b)  concretion. 

Infiltration. — The  deposition  of  calcium  phosphates  and  carbonates, 
often  with  similar  magnesium  salts,  occurs  either  in  the  cells  or  in  the 
matrix  binding  the  cells  together ;  these  salts  occur  first  in  the  form  of 
minute  granules  which  are  soluble  in  hydrochloric  acid,  often  with  an 
evolution  of  gas  if  carbonate  be  present.  The  granules  are  readily  stained 
by  hematoxylin,  and  gradually  fuse  into  homogeneous  masses  which  may 
have  a  concentric  arrangement. 

Forms  of  calcareous  infiltration. — (1)  Normally  it  is  observed  during  the 
formation  of  bone,  when  the  lime  salts  may  be  deposited  either  in  the  cartilaginous 


CALCIFICATION  &   CONCRETIONS — PIGMENTATION      15 

matrix  or  in  the  dense  osteoid  connective  tissue  substance.  (2)  It  occurs  in  senile 
tissues,  notably  in  cartilage,  e.g.  the  laryngeal  or  costal  cartilages,  which  may  even 
ossify ;  and  in  the  vessel  walls,  especially  in  the  intima  or  media,  where  it  is 
generally  preceded  by  a  morbid  lesion,  such  as  atheroma  or  fibrosis,  the  tissue 
being  in  an  impoverished  condition  on  account  of  a  weakened  circulation.  (3)  In 
continually  irritated  or  hyperplastic  connective  tissue,  the  result  of  so-called 
chronic  inflammation.  Thus  in  a  thickened  pleura  or  in  tendons  of  muscles 
constantly  exposed  to  pressure  {e.g.  from  riding),  calcareous  changes  are  not  rare, 
and  in  the  adventitious  fibrous  capsule  produced  by  the  continued  irritation  of 
parasites,  as  in  hydatid  and  trichina  cysts ;  in  this,  subsequently,  lime  salts  are 
deposited.  (4)  In  tumours,  such  as  fibromyomas  or  growths  containing  cartilage, 
calcareous  changes  are  by  no  means  uncommon.  When  cartilage  is  present,  the 
process  is  almost  physiological,  while  in  the  fibrous  tumours  those  parts  suffer 
which  are  furthest  removed  from  the  blood  supply,  or  which,  for  some 
other  reason,  have  their  vitality  impaired.  (5)  Calcareous  changes  are 
especially  common  in  caseating  or  necrosed  tissues,  and  wherever  fibrin  is 
present,  as  for  instance  in  thrombi,  infarcts,  or  endocarditis.  Hyaline  changes 
are  also  very  common  precursors  of  calcification.  Generally  speaking,  then, 
calcareous  infiltration  occurs  in  connection  with  a  dense  matrix  or  tissue,  dead 
or  necrosing  elements,  and  with  impaired  nutrition ;  it  is  therefore  intimately 
associated  with  degeneration  and  necrosis.  Soluble  calcium  salts,  lactate  or 
glycerophosphate  of  lime  in  the  blood,  and  lymph,  may  become  converted  into 
insoluble  salts,  the  carbonate  or  phosphate ;  while  at  the  same  time  there  is  a 
diminution  in  the  amount  of  fluids  keeping  the  lime  salts  in  solution. 

Concretions  are  calcareous  or  earthy  masses  occurring  in  pre- 
formed or  pre-existing  cavities,  in  the  lumen  of  vessels,  tubes,  or  ducts. 
They  may  be  found  in  serous  cavities,  when  they  generally  develop  in 
fibrinous  masses,  or  they  may  present  themselves  as  calculi.  In  the  latter 
case  the  lime  salts  are  generally  combined  with  other  substances,  and  they 
may  be  altogether  of  secondary  importance.  Calculi  are  found  in  the 
kidneys,  the  gall  bladder,  pancreatic  and  salivary  ducts,  the  prostate  and 
urinary  bladder ;  concretions  may  also  occur  in  the  intestine,  veins,  or 
tonsils,  as  enteroliths,  phleboliths  or  rhinoliths,  the  development  of 
which  is  generally  accompanied  by — (1)  stagnation  of  the  excretion  or 
secretion;  (2)  a  solid  substance,  it  may  be  a  small  crystal,  around 
which  the  incrustation  or  deposit  takes  place;  (3)  changes  in  the 
chemical  constitution  of  the  fluids  and  in  their  solvent  power,  which 
are  often  due  to  bacterial  activity  and  to  an  increase  of  albuminous, 
mucous,  or  colloid  substances.  Gouty  concretions,  which  consist  of  urate 
•of  sodium  mixed  with  carbonate  and  phosphate  of  lime,  will  be  considered 
elsewhere. 

Pigmentation. 

Pigment  may  be  of  little  or  no  importance,  or  it  may  be  of  the  greatest 
significance  in  the  diagnosis  of  disease.  The  pigment  may  be  exogenous, 
having  entered  from  without,  or  it  may  be  endogenous,  derived  from  the 
body  itself.  Examples  of  the  former  process  are  anthracosis,  where 
carbonaceous  matter  is  stored  up  in  the  lungs  or  lymphatic  glands,  the 
liver,  diaphragm,  and  other  parts ;  argyria,  where,  as  the  result  of  con- 
tinued ingestion  of  nitrate  of  silver,  salts  of  silver  are  deposited  in 
the  connective  tissue  and  vascular  walls  of  the  skin  and  kidneys ;  and 
tattooing,  where  insoluble  coloured  substances  are  rubbed  into  excoriated 
skin  and  its  lymphatics,  whence  in  part  they  are  carried  to  neighbouring 
lymphatic  glands. 


1 6  GENERAL  PA  THOL O GY  OF  DISEASE. 

Pigmentation. 


I.  Exogenous —  II.  Endogenous — 

Anthracosis.  i     tt  I  extravascular. 

.         .  1.  Haematogenous  <  .   ,  , 

Argyria.  °  \  intravascular. 

Tattooing.  2.  Overproduction. 

3.  Atrophic. 

4.  Hepatogenous. 

Such,  conditions  are  of  little  pathological  interest.  In  anthracosis  of  the 
glands  the  black  pigment  occurs  in  the  larger  connective  tissue  or  endothelial 
cells,  but  never  in  the  lymphocytes  themselves ;  in  anthracosis  of  the  lungs  the 
pigment  is  found  in  the  epithelial  cells  of  the  alveoli,  but  chiefly  in  the  inter- 
stitial connective  tissue  between  the  alveolar  walls,  where  it  lies  in  the  same 
type  of  cell  in  the  peribronchial  or  periarterial  tissue  (even  media  and  intima 
may  be  affected),  and  on  to  the  bronchial  glands.  The  deposited  pigment  acts 
like  other  foreign  bodies,  and  produces  a  hyperplasia  of  the  connective  tissue 
which  becomes  fibrous  (fibrosis  and  induration).  When  the  vessel  walls  are 
markedly  infiltrated,  they  appear  as  rings  of  pigment.  Anthracosis  affects 
especially  the  bronchial,  tracheal,  cervical,  portal,  and  mesenteric  glands.  Pass- 
ing along  the  lymph  sinuses,  this  pigment  is  taken  up  by  their  endothelium,  and 
is  at  first  deposited  around  the  periphery  of  the  lymph  follicles.  Its  presence 
produces  a  fibrosis  of  the  reticulum  just  as  it  did  in  the  lung,  and  many  of  the 
newly  formed  connective  tissue  cells  become  impregnated  with  pigment;  this 
gradually  extends  into  the  follicle,  which  becomes  indurated,  its  lymphocytes 
disappearing  before  the  proliferating  endothelial  or  connective  tissue  cells. 
Tattoo  pigments  are  taken  up  in  the  same  manner.  Where  the  pigment  is  of 
endogenous  origin,  it  may  have  been  derived  (1)  from  the  blood;  (2)  from  over- 
production due  to  an  increased  functional  activity  of  the  pigment  cells  ;  (3)  from 
certain  degeneration  processes ;  or  (4)  from  the  bile. 

Hematogenous  pigmentation  may  be  (a)  extravascular,  or  (b)  intravas- 
cular. In  the  former  case  it  may  result  from  a  haemorrhage  or  an  engorgement, 
with  diapedesis  and  destruction  of  the  red  blood  corpuscles.  The  pigment  is 
brownish  or  yellowish  in  colour,  and  consists  either  of  haematoidin  or  haemo- 
siderin.  Haeinatoidin  is  crystalline  acicular,  or  rhombohedral  and  free 
from  iron.  It  is  apparently  identical  with  bilirubin ;  but  it  includes  several 
substances,  all  iron-free  derivatives  of  haematin,  which  are  formed  in  and  by 
the  tissues  as  opposed  to  the  cells.  Haemosiderin,  on  the  other  hand,  an  iron- 
containing  granular  pigment,  is  manufactured  in  and  by  the  cells  themselves, 
which  have  taken  up  the  destroyed  red  corpuscles.  It  may  be  taken  to  the 
lymphatic  glands  by  the  wandering  cells.  Haemosiderin  and  haematoidin  often 
occur  together,  (b)  When  the  pigment  is  formed  inside  the  vessels  (1)  the 
blood  may  be  stagnating,  and  there  may  be  a  thrombosis,  when  a  state  of  things 
corresponding  to  that  existing  in  a  haemorrhage  is  present,  or  (2)  the  blood 
may  be  circulating.  Certain  poisons  may  cause  a  dissolution  of  the  red 
corpuscles  (a  haemolysis),  the  dissolved  haemoglobin  being  taken  up  by  the  blood 
plasma  (haemoglobinaemia),  to  be  excreted  by  the  kidneys  as  haemoglobin 
(haemoglobinuria),  which  may  be  present  in  such  quantities  that  it  may  even 
cause  a  brown  discoloration  of  the  uriniferous  tubules  (haemoglobin  infarcts). 
Experimentally,  haemolysis  may  be  produced  by  chlorate  of  potassium, 
arseniuretted  hydrogen,  and  toluol-diamine,  etc. 

In  other  cases  a  living  virus  may  attack  the  red  corpuscles  directly,  as  for 
instance  in  malaria,  where  an  iron-free  black  pigment  (melanin)  appears  in  the 
spleen,  liver,  brain,  and  bone  marrow,  and  is  also  deposited  in  the  skin  and 
tissues,  generally  together  with   haemosiderin.     Quincke  has   described   another 


PIG  ME  NT  A  TION  1 7 

process  of  haemal  pigmentation  which  he  calls  siderosis  ;  this  must  be  dis- 
tinguished from  siderosis  of  the  lung,  which  is  produced  by  inhalation  of  iron 
dust,  and  causes  a  rusty  brown  discoloration  of  the  lungs.  In  Quincke's  siderosis 
there  is  a  deposition  of  a  ferruginous  pigment  in  the  liver,  spleen,  marrow,  and 
often  also  in  the  kidneys ;  this  is  derived  from  the  red  corpuscles  which  die  in 
the  circulating  blood,  and  are  then  carried  by  phagocytic  cells  to  the  organs 
mentioned  above ;  from  them  a  yellow  hemosiderin  is  formed.  This  process  is  a 
physiological  one  according  to  Quincke,  but  under  pathological  conditions  there  is 
increased  haemolysis  accompanied  by  diminished  regeneration  of  red  corpuscles,  as 
for  instance  in  pernicious  anaemia,  when  the  presence  of  free  iron  can  easily  be 
demonstrated  in  the  liver,  spleen,  and  bone  marrow  by  means  of  chemical  reagents. 

Overproduction  of  pigment. — (a)  An  excessive  amount  of  brown  pigment 
may  appear  in  situations  which  normally  contain  such  pigment,  e.g.  the  skin, 
where,  for  some  reason  or  other,  the  pigment  cells  become  more  active  in  the 
elaboration  and  excretion  of  pigment.  Such  overproduction  may  be  physiological,  as 
in  the  pigmentation  of  pregnancy ;  and  in  freckles  (due  to  exposure  to  sunlight)  ;  it 
may  be  congenital,  in  pigmented  moles  (naevi  pigmentosi).  Again,  pigment  (melanin) 
may  occur  in  small  innocent  wart-like  or  mole-like  new  growths,  or  in  malignant 
deposits,  such  as  melanotic  sarcoma.  Melanin  is  free  from  iron,  but  contains 
sulphur.  In  Addison's  disease,  large  areas  may  be  pigmented,  but  as  yet  no 
sound  explanation  has  been  offered  as  to  the  origin  of  the  pigment  and  the 
relation  between  the  diseased  suprarenal  capsules  and  the  bronzing.  Histo- 
logically, wandering  cells  loaded  with  pigment  can  always  be  demonstrated  in  the 
skin  and  even  in  the  lymphatic  glands,  but  seldom  in  the  blood. 

(6)  Under  certain  pathological  conditions,  a  yellowish-green  pigment  may  appear 
in  morbid  growths,  more  especially  in  sarcomas  (chloromas),  and  in  the  so-called 
xanthoma  (xanthelasma),  which  is  occasionally  associated  with,  although  it  may 
occur  independently  of,  jaundice.     This  light  pigment  is  probably  a  lipochrome. 

Pigmentary  atrophy. — With  advancing  age  pigment  appears  in  several 
organs,  such  as  the  heart,  the  liver,  the  kidneys,  the  testes,  the  suprarenal 
capsules,  and  the  ganglion  cells  of  the  central  nervous  system.  The  origin  of 
this  pigment  has  not  been  satisfactorily  explained.  In  the  testes  and  liver  it  is 
ferruginous,  and  may  therefore  have  been  derived  from  the  blood,  but  in  the 
heart  it  is  iron-free.  Here  it  is  found  in  the  fibres  of  the  myocardium,  collected 
around  the  nuclei,  obscuring  the  striation  of  the  cells,  and  apart  from  senile 
changes  may  appear  as  the  result  of  a  cachexia  or  marasmus  (Addison's  disease), 
and  may  be  so  excessive  as  to  produce  a  yellow  or  brown  discoloration  (brown  or 
yellow  atrophy)  of  the  heart. 

Bile  pigmentation. — This  is  known  as  icterus  or  jaundice.  Under 
certain  pathological  conditions,  bile  pigment,  bilirubin,  passes  into  the  circulation 
by  the  thoracic  duct  from  the  hepatic  lymphatics.  In  this  condition  the  larger 
bile  ducts,  or  the  smaller  ducts  over  a  large  area  of  liver  tissue,  are  obstructed, 
or  there  is  a  regurgitation  of  bile  into  the  smaller  canaliculi  and  the  hepatic 
lymphatics.  It  is  always  hepatogenous,  that  is,  the  pigment  is  formed  by 
the  liver  and  in  the  liver,  and  not  in  the  blood  vessels.  The  pigment  appears 
in  the  tissues  first  as  bilirubin,  which  is  apparently  identical  with  haematoidin ; 
but  if  the  jaundice  persists,  the  bilirubin  is  gradually  oxidised  into  biliverdin, 
the  tint  of  the  skin  changing  from  yellow  to  dark  green  (black  jaundice). 
Bilirubin  absorbed  from  the  liver  appears  in  the  urine  as  such,  while  haematoidin 
appears  as  uribilin.  The  icteric  pigmentation  is  observed  in  the  following 
tissues : — Skin,  conjunctiva,  most  internal  organs,  the  intima  of  the  larger 
vessels,  the  liver  cells  and  the  renal  epithelium ;  it  is  also  found  in  the 
various  serous  fluids  and  in  sweat,  but  not  in  tears ;  the  brain  is  always  free. 
If  the  jaundice  is  of  long  standing,  the  bile  canaliculi  may  be  filled  with 
inspissated  bile. 

The  cause  of  the  yellow  discoloration  in  certain  forms  of  anaemia  (pernicious 
anaemia  and  leukaemia)  is  not  known. 
vol.  1. — 2 


GENERAL  PATHOLOGY  OE  DISEASE. 


Acute  Inflammation. 

Numerous  attempts  to  give  a  definition  of  acute  inflammation  have 
from  time  to  time  been  made,  but  none  of  them  have  been  altogether 
successful.  Metchnikoff,  studying  inflammation  chiefly  in  its  relation 
to  bacteria,  builds  up  a  theory  upon  phagocytosis  as  a  foundation.  He 
observes  the  reactions  of  the  tissue  of  mammals,  frogs,  crustaceans, 
and  amoebae  in  the  presence  of  micro-organisms,  and  finds  that  phago- 
cytosis is  the  one  phenomenon  which  is  seen  in  all  animals  in  the  struggle, 
and  therefrom  argues  that  it  is  the  primum  movens  of  inflamma- 
tion. Such  reasoning  appears  to  be  unsound  mainly  because  the  analogy 
is  incomplete,  and  it  is  highly  questionable  whether  it  is  possible,  by 
going  back  to  such  simple  animal  forms  as  daphnia  and  amoeba,  to  analyse 
such  an  extremely  complex  process  as  inflammation,  which,  so  far  as  it  is 
known  in  its  true  form,  occurs  only  in  extremely  complex  animals.  It  would 
be  as  rational  to  study  mental  activity  in  man  and  the  higher  animals 
by  examining  an  amoeba.  A  process  occurring  in  an  animal  possessed  of 
highly  differentiated  nervous  and  vascular  systems,  the  tissues  of  which, 
moreover,  are  highly  complex,  cannot  be  compared  with  any  process  observed 
in  an  animal  the  structure  of  which  is  very  simple,  or  is  represented  by 
a  single  cell.  In  defining  inflammation,  or  in  describing  it,  classes  of 
animals  homologous  in  structure,  and  known  to  react  by  what  is  recognised 
as  inflammation,  must  be  taken. 

Adami  gives  as  a  definition  of  inflammation,  "  the  local  attempt  at  repair  after 
an  injury,  actual  or  referred."  This  definition  includes  phenomena  which  no 
histologist  would  or  could  regard  as  inflammatory.  The  constant  renewal  of  the 
cuticle  would  be  inflammation.  An  injury — as,  for  instance,  superficial  epithelial 
lesions — may  be  repaired  without  what  is  generally  recognised  as  inflammation, 
i.e.  by  regeneration  and  direct  repair.  Some  low  forms  of  animal  life  are  capable 
of  regenerating  any  part  or  parts  of  their  body.  Regeneration  is  not  the  same 
as  repair  by  inflammation,  or  indirect  repair.  There  is  no  valid  reason  for 
extending  the  meaning  of  a  term  so  as  to  make  it  answer  the  requirements  of  a 
definition.  Inflammation  is  known  by  its  phenomena  and  its  appearances,  and  by 
the  changes  in  the  tissues,  and  unless  all  these  are  present  there  is  no  justification 
for  speaking  of  inflammation.  A  certain  process  or  an  attempt  at  repair  in  a  low 
form  of  animal  may  in  some  or  in  many  of  its  phenomena  resemble  inflammation, 
and  still  not  be  inflammation,  which  is  a  complex  process  and  occurs  in  complex 
tissues  and  whose  criterion  should  be  what  is  known  to  occur  in  such  tissues,  and 
nothing  should  be  called  inflammation  that  does  not  agree  with  observations  on 
animals  in  which  the  recognised  tissue  reactions  of  inflammation  may  be  met  with. 

Starting  from  this  point,  it  will  be  found  that  acute  inflammation  is 
a  reaction  of  mixed  tissues,  which  occurs  only  in  man  and  other  vascular 
animals ;  it  is  a  uniform  process,  varying,  no  doubt,  in  its  different  types, 
but  in  degree  only,  not  in  kind ;  there  is  a  uniformity  in  the  pathogenesis, 
progress,  and  morphological  attributes  of  acute  inflammatory  conditions, 
which  is  so  striking  that  nothing  should  be  called  inflammation,  unless  it 
presents  all  the  essential  phenomena  which  the  study  of  disease  in  man 
and  other  vascular  animals  has  revealed  to  us.  To  select  phagocytosis, 
or  chemiotaxis,  or  new  formation  and  repair  as  essentials,  and  make  them 
the  corner-stones  of  theories  of  inflammation,  is  unjustifiable.  Phagocytosis, 
chemiotaxis,  and  proliferation  are  concomitant,  or  it  may  be  constant, 
phenomena  of  acute  inflammation,  and  each  one  of  them  may  be  traced 


ACUTE  INFLAMMATION.  19 

back  from  the  highest  to  the  lowest  form  of  animal ;  but  surely  it  is  not 
sound  reasoning  to  evolve  the  whole  process  of  inflammation  from  one 
or  two  of  its  phenomena,  especially  when  such  phenomena  are  very 
primitive  protoplasmic  properties.  Evolution  may  teach  how  a  property 
or  a  character  has  been  acquired ;  it  may  indicate  something  of  the 
phylogenetic  origin  of  an  organ  or  a  process ;  but  it  nowhere  teaches  that 
a  complex  process  in  a  higher  animal  type,  which  can  be  traced  back  to 
some  property  or  function  in  a  lower  type,  is  identical  with  this  property 
or  function.  In  any  appeal  to  evolution,  the  thread  is  often  lost  and 
many  gaps  cannot  be  filled.  Inflammation,  as  it  is  known  to  the  human 
pathologist,  occurs  only  in  certain  higher  animals  in  which  there  is  a  blood 
vascular  system.  This  is  the  line  of  demarcation.  A  vascular  animal  reacts 
to  a  certain  stimulus  by  inflammation,  while  the  same  stimulus  in  an 
avascular  animal  may  produce  some  phenomenon  which  also  occurs  in 
inflammation,  but  of  itself  is  not  inflammation. 

Analysing  the  process  of  inflammation,  it  is  found  that  (1)  without 
blood  vessels  there  is  no  inflammation ;  (2)  it  is  a  reaction  of  vascular 
connective  tissue  or  of  connective  tissue,  itself  perhaps  avascular,  but  in 
close  relation  with  the  vascular  system.  Inflammation  of  epithelium  does 
not  exist,  and  true  inflammation  in  really  avascular  connective  tissues, 
such  as  cartilage,  has  not  been  observed.  Inflammation  in  avascular 
tissue  is  said  to  occur  in  the  cornea,  but  here  an  anatomically  avascular 
tissue  is  in  close  connection  with  the  circulation  by  means  of  the  vessels 
at  its  periphery  and  its  numerous  lymph  channels.  So  slight  a  lesion  of 
the  cornea,  in  which  there  is  nothing  more  than  a  limited  destruction  and 
proliferation  of  the  corneal  corpuscles,  is  not  and  does  not  end  in  inflam- 
mation ;  there  is  simply  direct  repair ;  any  tissue  that  has  life  left  after  an 
injury  or  a  loss  of  substance  will  at  once  repair  itself  or  regenerate.  As 
soon  as  the  injury  is  severe  enough  to  transmit  its  influence  to  the  vessels 
around  the  cornea,  all  the  changes  of  inflammation  become  evident.  The 
cornea,  therefore,  is  a  connective  tissue  which  is  subject  to  inflammation  if 
the  stimulus  be  adequate ;  if  not,  repair  occurs  without  inflammation.  An 
irritant  may  produce  different  effects  according  to  its  intensity  and  the 
method  of  application  ;  it  may  produce  a  slight  injury,  easily  and  directly 
repaired ;  or  a  serious  injury,  followed  by  immediate  death  or  slow  necrosis, 
or  followed  by  secondary  inflammation ;  or  it  may  produce  an  acute  primary 
inflammation.  ISTow,  because  the  same  irritant  is  applied  to  a  graduated 
series  of  tissue  and  animals,  it  is  not  justifiable  to  assert  that  the  effect  of 
its  action  is  one  and  the  same  process  in  all  cases.  No  doubt,  if  the 
different  effects  produced  are  compared,  there  is  a  gradual  transition  from 
one  to  the  other,  but  so  there  is  from  an  innocent  to  a  malignant  growth. 

A  smaller  number  of  vibrations  of  the  mysterious  ether  results  in  the 
subjective  sensation  of  heat,  while  more  rapid  vibration  of  the  same 
ether  produces  one  of  light ;  yet  heat  is  not  light.  The  cornea  experiments 
cannot  be  used  as  arguments  against  the  view,  originally  supported  by 
Cohnheim,  that  inflammation  can  occur  only  in  vascular  tissues,  for  as 
soon  as  changes  which  everyone  would  recognise  as  inflammation  are  set 
up  in  the  vessels  around  the  cornea,  the  tissue  in  which  they  lie  has 
reacted,  being,  so  to  speak,  drawn  into  the  zone  of  irritation  through  the 
innumerable  lymph  channels.  Inflammation,  then,  must  be  regarded  as  a 
series  of  changes,  occurring  only  in  vascular  or  vascularisable  connective 
tissue,  or  in  connective  tissue  in  close  connection  with  the  surrounding 
blood  vessels. 


2o  GENERAL  PATHOLOGY  OF  DISEASE. 

Causation. — It  is  only  necessary  to  mention  here  that  traumatic, 
chemical,  or  physical  irritants,  including  foreign  bodies  and  micro- 
organisms, are  capable  of  reacting  on  the  connective  tissue  in  such  a 
manner  as  to  produce  the  phenomena  and  appearances  of  inflammation. 
These  irritants  must  possess  a  certain  relative  intensity,  otherwise  inflam- 
mation may  not  set  in ;  or  if  the  intensity  is  too  great,  necrosis  may  be  the 
result.  The  intensity  will,  of  course,  vary  with  the  general  or  local  tissue 
resistance  of  the  individual.  In  certain  diseased  conditions,  inflammation 
is  readily  produced  by  conditions  which  are  incapable  of  producing  it  in 
health. 

Processes. — In  acute  inflammation,  two  main  processes  may  be 
distinguished — (a)  exudative,  and  (b)  proliferative. 

The  exudative  processes  are,  speaking  generally,  most  evident  during  the 
earlier  stages,  and  are  concerned  especially  with  the  vessels.  Fluid  and  cells  may 
pass  through  the  vessel  wall,  the  fluid  being  coagulable  lymph,  which  may  or 
may  not  coagulate,  the  cells  being  leucocytes  and  red  corpuscles.  The  proliferat- 
ive processes  are  observed  in  the  connective  tissue  and  endothelium,  and  in  the 
vessels.  The  fixed  and  wandering  connective  tissue  cells  multiply,  and  so  do  the 
endothelial  cells  lying  in  the  lymph  spaces,  and  lining  the  capillary  and  lymphatic 
walls.  These  proliferative  changes  are  best  seen  in  the  later  stages  of  acute 
inflammation.  It  appears,  therefore,  that  in  the  earlier  stages,  if  many  cells  are 
present  in  the  inflamed  area,  they  are  mainly  leucocytes  (leucocytic  infiltration) ; 
while  in  the  later  stages  the  cells  are  mostly  derived  from  the  connective  tissue 
or  endothelium.  The  products  of  proliferation,  if  repair  follows,  become  con- 
verted into  fresh  connective  or  fibrous  tissue,  but  when  this  occurs  inflammation 
is  at  an  end.  Speaking  generally,  it  may  be  said  that  the  more  vascular  a  part  is, 
the  more  evident  are  the  exudative  changes  during  the  earlier  stages ;  and, 
conversely,  the  less  vascular  a  part  is,  the  more  marked  are  the  proliferative 
changes  during  the  earlier  stages.  In  any  process  which  is  recognised  as  inflam- 
mation, both  exudative  and  proliferative  changes  always  occur. 


Acute  Inflammation  {Connective  Tissue  Reaction). 


Exudative  Processes. 


Vessels. 


Proliferative  Processes. 


Connective  Tissue. 


Vessels  and 
Lymphatics. 


Fluid  (fibrin). 


Cells— 

(a)  Leucocytes  (leucocytic 
infiltration). 

(6)  Red  corpuscles. 


(a)  Fixed  cells.  Endothelium. 

(b)  "Wandering    cells    (small 

round-cell  infiltration). 

Repair — New  connective  or  fibrous  tissue 
and  vessels. 


If  the  process  of  acute  inflammation  in  the  frog's  mesentery  be  carefully 
watched,  it  will  be  found  that  dilatation  of  the  small  arteries  (inflammatory 
congestion)  first  makes  its  appearance,  and  reaches  its  height  in  a  few  hours. 
More  blood  flows  into  the  part,  and  the  veins  not  participating  in  the  dilatation, 
the  velocity  of  the  blood  flow  is  increased.  Gradually,  but  more  slowly,  the 
veins  and  capillaries  dilate,  and  arteries,  capillaries,  and  veins  become  turgid, 
and  there  is  a  retardation  of  the  blood  flow,  the  leucocytes  arranging  themselves 
along  the  walls  of  the  veins  preparatory  to  their  emigration.     In  the  capillaries, 


ACUTE  INFLAMMATION,  EXUDATIONS.  21 

analogous  changes  are  observed :  in  some  the  blood  still  travels  onwards ;  in 
others  there  is  merely  a  flow  of  plasma-like  fluid ;  while  in  many  the  current  has 
ceased  altogether  (stasis),  the  capillary  being  filled  with  red  corpuscles,  or  some- 
times with  plugs  of  white  corpuscles  (white  stasis).  Emigration  (an  active 
process)  of  leucocytes  follows,  as  in  the  veins ;  pseudopodia  are  sent  out  through 
the  vessel  wall,  the  whole  leucocyte  gradually  following  the  extruded  part. 
This  is  accompanied  by  a  diapedesis  of  the  red  corpuscles,  at  times  but  slight, 
at  other  times  very  marked,  but  always  present.  Amongst  and  between  the 
capillaries  numbers  of  scattered  or  aggregated  white  and  red  corpuscles  are  to  be 
seen  at  this  stage.  At  the  same  time  there  is  also  a  transudation  of  fluid  (plasma), 
sometimes  so  considerable  in  amount  that  the  part  becomes  cedematous  (inflam- 
matory oedema). 

Exactly  similar  phenomena  are  seen  in  the  inflamed  mesentery  of  warm- 
blooded animals,  or  in  the  irritated  cornea,  the  vessels  at  the  corneal  margin 
becoming  dilated,  this  being  accompanied  by  a  copious  diapedesis  and  transuda- 
tion of  fluid. 

The  following  is  a  summary  of  these  conditions : — 

Dilatation  of  arterial  vessels  (inflammatory  congestion  and  increased 
velocity). 

Dilatation  of  capillaries  and  veins  (retardation). 

With  retardation :  marginal  arrangement  of  leucocytes. 

In  the  capillaries  there  may  be  complete  stasis ; 

Followed  by  diapedesis  of  white  and  red  corpuscles. 

Transudation  (inflammatory  oedema). 

Although  the  process  of  emigration  must  be  regarded  as  an  active  one 
on  the  part  of  the  white  corpuscles,  certain  co-operating  factors  must  not 
be  lost  sight  "of — (1)  Changes  in  blood  current:  the  quickened  stream  by 
centrifugal  action  drives  the  corpuscles,  which  normally  travel  centrally, 
against  the  vessel  wall,  where  they  are  inclined  to  adhere  on  account  of 
their  stickiness  during  the  retardation  stage.  When  there  is  stasis,  the 
marginal  distribution  of  the  leucocytes  is  entirely  absent.  (2)  Increased 
capillary  and  venous  pressure  must  to  some  extent  assist  diapedesis, 
especially  when  (3)  the  permeability  of  the  delicate  vessel  wall  is 
increased.  That  the  vessel  wall  becomes  more  porous  can  hardly  be 
questioned.  (4)  Lastly,  the  vessel  wall  must  be  in  a  suitable  condition  to 
allow  the  leucocytes  to  adhere.  Before  emigration  can  occur,  it  appears, 
therefore,  that  certain  conditions  must  exist — (a)  changes  in  the  blood 
current,  to  allow  of  a  marginal  distribution  of  the  leucocytes ;  (b)  a  suitable 
state  of  the  vessel  wall,  without  which  adhesion  cannot  take  place;  (c) 
amoeboid  activity  of  the  white  corpuscles.  Substances  which  paralyse  the 
amoeboid  movements  of  the  white  corpuscles  completely  stop  diapedesis. 

Amoeboid  leucocytes  outside  the  animal  body,  whenever  they  come  in 
contact  with  the  surface  of  a  foreign  body,  attach  themselves  and  become 
flattened  out ;  and  if  the  foreign  body  be  porous,  having  attached  them- 
selves, they  send  out  pseudopodia  into  the  pores.  It  is  important  to 
remember  that  this  tactile  sensibility  of  the  amoeboid  leucocyte  is  a 
natural  property.  When  the  corpuscle  comes  in  contact  with  the  vessel 
wall,  it  becomes  flattened  out,  attaches  itself,  sends  a  pseudopodium 
through  any  pore  there  may  be  in  the  vessel  wTall,  and  then  creeps  into  the 
surrounding  connective  tissue.  If  the  irritant  which  causes  the  inflam- 
mation is  such  that  it  does  not  paralyse  the  protoplasm  of  the  leucocyte, 
nor  prevent  the  vessel  wall  from  responding  to  its  tactile  sensibility  of 
adhesiveness,  emigration  must  take  place. 


22  GENERAL  PATHOLOGY  OF  DLSEASE. 

The  leucocytes,  having  passed  out  of  the  vessel,  begin  to  wander — 
migration  to  the  seat  of  irritation.  This  is  also  mainly  a  pseudopodial 
act,  although  it  is  no  doubt  favoured  by  concomitant  conditions,  such  as 
the  exudation  currents  and  the  diminished  resistance  of  the  tissues.  This 
migration  to  the  seat  of  irritation  is  due  chiefly  to  an  attraction  of  the 
leucocytes  by  the  chemical  products  of  bacterial  activity  or  tissue 
destruction,  i.e.  chemiotaxis.  Certain  substances,  amongst  which  are 
albuminous  bodies  contained  in  the  bacteria  (proteins),  and  the  earlier 
products  of  decomposition  or  necrosis,  attract  leucocytes.  That  chemio- 
taxis, or  rather  the  chemiotactic  irritability  of  the  leucocytes,  is  an 
important  factor  in  the  migration,  cannot  be  questioned ;  but  it  does  not 
explain  altogether  why  the  cells  collect  in  the  inflamed  area.  In 
pneumonia,  for  instance,  where  a  whole  consolidated  lobe  may  show  all 
the  alveoli  full  of  leucocytes,  it  is  difficult  to  explain  such  extensive 
aggregation  on  the  principle  of  chemiotaxis.  A  local  and  circumscribed 
attraction  may  be  so  brought  about,  but  matters  are  different  when  a 
whole  organ  is  invaded.  Moreover,  if  the  aggregation  of  leucocytes  in 
the  inflamed  lung  were  due  to  chemiotaxis,  the  blood  in  the  peripheral 
circulation  should  be  impoverished  in  white  corpuscles.  The  contrary, 
however,  is  the  case,  for  in  most  cases  of  pneumonia  which  run  a  favour- 
able course  there  is  an  extraordinary  leucocytosis. 

The  various  forms  of  leucocytes  do  not  show  an  equal  tendency  towards 
diapedesis  or  migration.  In  circulating  blood,  the  following  general  types  of 
white  corpuscles  occur,  viz. — (1)  The  lymphocytes;  (2)  the  multinuclear; 
(3)  the  large  uninuclear ;  and  (4)  the  coarsely  granular  eosinophile  cells.  The 
small  lymphocytes  consist  of  scanty  protoplasm,  covering  a  round  nucleus,  and 
are  indistinguishable  from  the  small  cells  of  lymphoid  tissue.  They  may  form  up 
to  30  per  cent,  of  the  leucocytes  present  in  human  blood.  The  large  uninuclear 
cells  have  a  round  or  kidney-shaped  nucleus  and  abundant  protoplasm,  and  are 
rare  in  the  blood  (2  per  cent.).  The  multinuclear  or  polymorphonuclear  cells 
have  a  lobed  or  multipartite  nucleus,  and  their  protoplasm  is  beset  with  small 
granules,  staining  red  with  eosin.  They  are  abundant  in  the  blood  (up  to  70 
per  cent.),  and  are  actively  amoeboid  and  phagocytic.  The  coarsely  granular  cell 
shows  large  and  numerous  granules,  staining  deeply  with  eosin ;  they  are  rare  in 
human  blood  (up  to  5  per  cent.),  are  amoeboid,  but  not  phagocytic.  During  the 
earlier  stages  of  inflammation,  when  chemiotaxis  is  said  to  be  most  active,  the 
multinuclear  (neutrophile)  cells  leave  the  vessels  in  greatest  number  and  migrate 
to  the  irritated  area,  forming  the  bulk  of  the  pus  corpuscles.  Sometimes 
the  coarsely  granular  eosinophile  cells  also  appear  in  large  numbers.  This 
"  selective  attraction "  proves  that  we  must  not  take  the  process  of  chemiotaxis 
too  literally.  The  cells  which  migrate  to  the  inflammatory  focus  are  the  most 
plastic  and  amoeboid  among  the  leucocytes,  and  this  demonstrates  the  close 
relation  which  must  exist  between  so-called  chemiotaxis,  tactile  sensibility,  and 
motility.  These  leucocytes,  coming  up,  draw  a  cordon  around  the  inflammatory 
zone,  and  prevent  absorption  of  the  toxic  material.  Moreover,  the  cells  being 
phagocytic,  they  not  only  destroy  the  irritant,  but  assist  in  clearing  away  the 
tissue  d6bris,  so  preparing  the  ground  for  the  proliferating  connective  tissue.  At 
times,  however,  they  have  to  collect  in  such  enormous  numbers  that  suppuration 
appears. 

A  fluid  transudation,  differing  but  little  in  composition  from  ordinary 
plasma,  also  leaves  the  vessels.  There  is  a  normal  process  of  lymph  trans- 
udation, exaggerated  as  the  result  of  inflammation,  varying  with  the  laxity 
of  the  tissues,  the  nature  of  the  irritant  and  the  animal,  and  inversely  as 
the  resistance  of  the  tissues.     There  is  thus  a  flushing  out  of  the  part 


SER  O  US  EFFUSION  IN  INFLAMMA  TION  2  3 

and  a  removal,  or  at  any  rate  a  dilution  of  the  poisonous  irritant.  This 
may  bring  about  an  increase  of  the  chemiotactic  process,  for  it  has  been 
shown  by  experiments  that  strong  solutions  of  certain  substances  may 
paralyse  the  tactile  sensibility  and  the  motility  of  the  amoeboid  leucocytes, 
while  when  diluted  the  same  solution  may  produce  an  attraction  for  these 
corpuscles.  This  fluid  may  supply  the  proliferating  tissues  with  nourish- 
ment ;  on  the  other  hand,  however,  it  may  prove  harmful  by  impairing 
nutrition,  by  the  tissues  becoming  water-logged,  by  pressure  on  vital  organs, 
and  even  on  the  cells  of  tissues. 

Transudation  appears  to  be  due  to  three  chief  factors,  namely,  (1)  the  increased 
permeability  of  the  capillary  wall ;  (2)  an  increased  lymph  secretion ;  and  (3)  a 
diminished  lymph  absorption.  Some  observers  deny  that  there  is  a  true  lymph 
secretion,  but  regard  the  process  as  a  mechanical  one,  i.e.  a  filtration  under 
pressure,  and,  according  to  them,  instead  of  increased  lymph  secretion,  increased 
filtration  must  be  due  to  raised  intracapillary  pressure. 

The  inflammatory  exudation  consists  of  plasma  or  a  plasmatic  fluid, 
various  enzymes  and  toxins  derived  from  bacteria,  and  certain  germicidal 
substances,  tissue  cells,  mucin,  leucocytes,  fibrin  and  its  precursors, 
albumoses,  and  peptones.  The  exudation  may  or  may  not  coagulate, 
according  to  the  presence  or  absence  of  the  fibrin-forming  substance. 

Fibrinous  inflammation. — Under  physiological  conditions,  plasma 
will  coagulate  outside  the  body,  on  the  addition  of  fibrin  ferment  or 
leucocytes;  it  may  be  argued,  therefore,  that  in  inflammation,  wherever 
leucocytes  are  present,  fibrin  is  formed.  The  absence  of  coagulation  in 
the  case  of  serous  effusion  requires  explanation.  It  appears  to  be  due 
largely  to  certain  inhibitory  influences,  amongst  which  may  be  mentioned — 
(a)  integrity  of  the  endothelial  or  epithelial  surface ;  (b)  absence  of  fibrin 
ferment  and  leucocytes ;  (c)  increased  alkalinity ;  and  (d)  the  presence  of 
certain  toxic  or  chemical  substances  which,  in  small  quantities,  are  capable 
of  preventing  coagulation.  Thus,  extremely  minute  quantities  of  cobra 
poison  will  prevent  coagulation,  and  certain  bacterial  substances  or  tissue 
products  appear  to  be  possessed  of  similar  powers. 

Fibrin  generally  appears  on  free  surfaces  or  in  enclosed  spaces 
(tonsils,  pleura,  and  pericardium),  especially  when  there  is  continued 
rubbing  of  the  surfaces  of  organs  (heart  and  lungs),  or  as  the  result  of  the 
action  of  chemical  substances,  as  in  diphtheria  and  pneumonia.  It  may  be 
formed  either  immediately  or  after  some  delay,  the  exudation  at  first 
serous,  later  becoming  fibrinous ;  it  may  form  a  true  membrane  lying 
on  the  free  surface,  as  in  fibrinous  pericarditis,  or  it  may  form  an  inter- 
stitial deposit,  as  in  diphtheria,  where  the  fibrin  appears  between  and 
among  the  epithelial  cells,  which  undergo  a  so-called  coagulation  necrosis. 

Serous  inflammation. — If  the  exuded  plasma  does  not  coagulate, 
the  inflammation  is  said  to  be  serous.  The  fluid  poured  out,  which  varies 
considerably  in  amount,  generally  speaking  exudes  most  copiously  from 
a  free  surface,  which  may  be  lined  by  epithelium,  columnar  in  the  nose, 
larynx,  intestine,  or  uterus,  or  squamous  on  the  conjunctiva  and  vagina. 
A  serous  inflammation  on  such  free  epithelial  surfaces  is  called  a  catarrh ; 
the  exudation  then  contains  much  mucus.  The  effusion  may  exude 
from  an  endothelial  surface,  such  as  the  pleura  or  peritoneum.  It  is 
possible  that  coagulation  does  not  occur,  because  the  epithelium  or  endo- 
thelium is  intact,  or  because  there  are  other  inhibitory  influences  which 
prevent  coagulation. 


24 


GENERAL  PATHOLOGY  OF  DLSEASE. 


Instead  of  escaping  to  a  free  surface,  the  exudation  may  collect  in  the  tissue 
substance,  e.g.  as  in  interstitial  serous  infiltration,  in  the  connective  tissue 
(inflammatory  cedema),  or  between  layers  of  epithelium  (vesiculation).  An 
inflammatory  cedema  is  often  observed ;  extensive  fibrin  formation,  as  in 
croupous  pneumonia,  where,  on  cutting  into  the  consolidated  lung,  fluid  generally 
exudes  copiously;  again,  the  serous  effusion  may  subsequently  coagulate  either 
completely  or  in  part,  producing  a  so-called  sero-fibrinous  inflammation.  In 
cellulitis  and  acute  septic  inflammations,  the  cedematous  infiltration  is,  as  a  rule, 
well  marked ;  indeed,  speaking  generally,  the  weaker  the  local  or  general  resist- 
ance of  the  individual,  the  more  marked  is  the  inflammatory  cedema.  The  fluid 
which  is  poured  out  may  be  completely  absorbed,  or  it  may  stagnate,  then  leading 
to  a  chronic  or  persistent  effusion,  or  to  necrosis  and  gangrene  from  the  impair- 
ment of  the  nutrition  of  the  tissues,  which  become  softened  and  waterlogged. 


Fluid  Constituent  of  Inflammatory  Exudation 
Coagulation  =  fibrinous  inflammation. 


(a)  Interstitial  =  diphtheria. 

(b)  Free  endothelial  surf  aces  =  fibrin- 

ous pleurisy. 

(c)  Free    epithelial   surfaces  =  mem- 

branous   tonsillitis,     croupous 
pneumonia. 

( Destruction     and      removal  = 
Result  <       resolution. 

(  Organisation  =  induration. 


{sero- 
fibrinous, 
sero- 
purulent. 

(a)  Interstitial  =  inflammatory  oedema, 

vesicles. 

(b)  Tree  endothelial  surfaces  =  serous 

effusion. 

(c)  Free   epithelial  surf  aces  =  catarrh. 


Result 


Discharge  =  catarrh       (restitu- 
tion). 

Absorption  =  resolution. 
\  Stagnation  =  chronic  effusion. 
I  Coagulation  =  fibrinous  or  sere- 
in    fibrinous  inflammation  (q.v.). 


Purulent  inflammation. — When  emigration  and  aggregation  of 
leucocytes  are  excessive,  and  there  is  no  coagulation,  the  exudation  becomes 
converted  into  pus.  Microscopically,  the  so-called  laudable  pus  of  the  older 
writers  is  a  thick,  viscid,  light  yellow,  or  yellowish  fluid,  with  a  faintly 
sweetish,  sickly  odour ;  on  standing,  it  separates  into  two  portions,  a 
serous  element,  the  liquor  puris,  and  a  whitish  sediment,  the  pus  corpuscles. 
Although  pus  consists  of  inflammatory  plasma  and  leucocytes,  it  does  not 
coagulate,  so  that  there  must  have  been  influences  or  substances  at  work 
which,  during  the  process  of  pus  formation,  inhibited  coagulation.  Micro- 
scopically, the  most  important  constituents  of  pus  are  the  pus  corpuscles, 
which  are  mostly  of  leucocytic  origin.  In  fibrinous  inflammation,  e.g.  in 
pneumonia,  where  the  number  of  white  corpuscles  present  may  be  as 
great  as  in  pus,  the  process  cannot  be  compared  to  a  suppuration,  as 
has  been  done  by  some  observers.  The  leucocytes,  which  constitute  the 
pus  corpuscles,  are  mostly  actively  amoeboid,  and  are  usually  of  the  so- 
called  polymorpho-nuclear  or  neutrophile  variety ;  sometimes,  however,  the 
number  of  coarsely  granular  eosinophile  cells  present  is  striking.  Young 
connective  tissue  cells  are  also  often  found  amongst  the  pus  corpuscles ; 
many  of  the  cells  are  degenerated  or  dead,  but  many  are  still  amoeboid, 
well  preserved,  and  phagocytic,  as  may  be  seen  on  placing  fresh  pus  on  the 
warm  stage  of  a  microscope. 


FORMATION  OF  PUS. 


25 


Pathogenesis  of  suppuration. — In  most  cases  micro-organisms 
are  present,  and  it  must  be  concluded  that  pus  is  usually  of  bacterial 
origin.  It  is  possible,  however,  by  means  of  nitrate  of  silver,  turpentine, 
castor-oil,  perchloride  of  mercury,  and  other  chemical  substances,  to  produce 
a  suppuration  without  micro-organisms  appearing  (sterile  suppuration). 
Similarly,  continued  irritation,  e.g.  the  presence  of  metal  in  the  anterior 
chamber  of  the  eye  and  the  products  of  necrosis,  may  call  forth  a  suppurat- 
ive process.  Chemical  irritation,  therefore,  may  be  a  cause  of  suppura- 
tion. Buchner  has  shown  that  castor-oil  causes  a  necrosis  of  the  tissues. 
and  that  the  products  of  this  necrosis  have  a  positive  chemiotactic  action, 
i.e.  they  attract  leucocytes,  and  that  suppuration  is  thus  set  up. 

Most  cases,  however,  are  of  bacterial  origin,  a  fact  which  the  surgeon 
especially  should  remember ;  and  certain  micrococci  are  so  constantly  found 
in  pus,  that  they  are  regarded  as  pus-producing  or  pyogenetic  organisms. 
The  commonest  forms  are  the  following : — (1)  Staphylococci :  (a)  Staphylo- 
coccus pyogenes  aureus  ;  (b)  Staphylococcus  pyogenes  albus ;  (c)  Staphylococcus 
pyogenes  citreus.  (2)  Streptococci :  (a)  Streptococcus  pyogenes ;  (b)  Strepto- 
coccus erysipelatis ;  (c)  Pneumococcus.  Each  variety  may  occur  alone,  but 
mixed  purulent  infections  are  frequently  met  with.  Other  microbes  may 
produce  a  suppuration,  e.g.  the  bacillus  of  typhoid  fever,  the  gonococcus 
and  the  bacillus  of  tuberculosis ;  but  they  are  so  markedly  specific  in  their 
action,  that  they  are  not  included  among  the  pyogenetic  organisms.  How 
do  these  germs  produce  suppuration  ?  Buchner  has  clearly  shown  that 
they  act  by  chemical  irritation,  for  the  dead  bodies  or  the  protoplasmic  sub- 
stances (proteins)  of  the  bacteria  produce  suppuration  as  effectively  as,  or 
even  better  than,  the  living  organisms.  The  chemical  irritant  is  extremely 
chemiotactic,  and  stimulates  the  leucocytes  to  emigrate  and  to  wander  to 
the  seat  of  lesion.  There  appear  to  be  two  necessary  conditions,  without 
which  there  can  be  no  pus — (1)  chemiotaxis  and  aggregation  of  leucocytes, 
and  (2)  inhibition  of  coagulation.  A  third  factor  is  histolysis  or  tissue 
destruction.  Under  the  influence  of  pus  formation,  the  tissues  are  dis- 
solved and  disintegrated,  and,  according  to  the  law  of  repair,  they  react 
against  this  dissolution  by  proliferation  and  an  attempt  to  form  new  cells. 
This  may  be  observed  at  the  margins  of  any  suppurating  focus,  and  it  is 
for  this  reason  that  connective  tissue  cells  are  so  frequently  found  in  pus. 

The  fluid  constituent  of  pus  is  serum  devoid  of  fibrinogen,  but  contain- 
ing albumoses  and  peptones,  toxines  of  bacterial  origin,  and  various  products 
of  degeneration.  The  albumoses  and  peptones  are  in  part  due  to  the 
digestive  or  proteolytic  action  of  the  micro-organisms  concerned,  and  partly 
to  a  similar  action  on  the  part  of  the  pus  corpuscles  themselves ;  indeed,  it 
is  probable  that  the  histolysis  depends  on  this  proteolytic  property  of  pus. 
Pus  forms  a  bad  soil  for  the  growth  of  bacteria ;  it  has,  indeed,  a  distinctly 
germicidal  action,  and  long  pent  up  in  the  body  becomes  sterile,  the  pyo- 
cocci being  gradually  destroyed.  The  chief  physiological  properties  of  pus, 
therefore,  are  the  following : — It  is  (1)  bactericidal,  (2)  histolytic,  (3)  con- 
tains phagocytic  elements,  and  (4)  is  a  strong  solvent,  for  Leber  has  shown 
that  it  is  capable  of  dissolving  such  metals  as  platinum  and  copper,  which 
require  strong  acids  for  their  solution.  There  can  be  no  doubt  that  sup- 
puration must  frequently  be  a  useful  issue  of  the  inflammatory  process, 
assisting  in  the  destruction  of  the  irritant,  and  stimulating  the  tissues  to 
react  by  proliferation.  It  is  often,  however,  a  source  of  danger,  leading  to 
the  destruction  of  the  tissues,  laying  open  the  vessels,  and  thus  offering 
openings  for  serious  complications,  such  as  septicaemia  and  pyaemia. 


26  GENERAL  PATHOLOGY  OF  DISEASE. 

It  would  be  erroneous  to  suppose  that  pyogenetic  microbes  have  an  absolutely 
specific  action,  and  are  capable  of  producing  suppuration  only.  Suppuration  is 
merely  the  outward  expression  of  certain  inflammatory  processes,  and  it  is  not 
even  the  most  serious  phase  or  variety  of  inflammation.  As  a  matter  of  fact,  it 
found  that  the  same  species  of  organisms  may  produce  a  slight  local 
inflammation  or  an  extensive  spreading  inflammation,  a  small  local  suppuration  or 
a  large  acute  abscess,  an  erysipelas  or  a  cellulitis,  a  pneumonia,  a  septicaemia,  an 
infective  endocarditis,  or  a  pyaemia.  Thus  a  small  acne  pustule  may  contain  one 
or  more  varieties  of  pyococci.  It  may  grow  into  a  boil,  the  latter  into  a  carbuncle, 
which,  again,  may  be  followed  by  septicaemia  or  pyaemia.  The  pneumococcus  may 
be  found  in  pneumonia,  in  suppurative  otitis  media,  in  angina  Ludovici,  in  infective 
endocarditis,  peritonitis,  and  pleurisy.  Almost  all  vegetable  micro-organisms 
possess  the  faculty  of  producing  an  inflammation,  and  those  which  are  most  fre- 
quently found  in  primary  inflammatory  processes  are  called  pyogenetic,  but  whether 
they  produce  a  benign  form  of  inflammation,  or  a  suppuration,  an  oedematous  or 
a  necrotic  inflammatory  lesion,  will  depend  chiefly  on  the  virulence  of  the  bacteria, 
and  the  local  conditions,  the  local  or  general  resistance,  on  the  quantity  of  bacteria 
introduced,  and  on  the  continuance  of  the  supply  of  micro-organisms,  i.e.  whether 
there  is  a  single  or  a  continued  invasion  of  micro-organisms.  Under  favourable 
conditions,  i.e.  if  the  virulence  of  the  bacteria  be  reduced,  or  the  resistance  exalted, 
an  innocent  local  inflammation  may  ensue ;  as  the  virulence  increases,  or  as  the 
resistance  decreases,  suppuration  makes  its  appearance ;  and  if  the  virulence  is 
excessive,  and  the  resistance  slight,  an  oedematous,  necrotic,  or  gangrenous 
inflammation  is  produced.  Septicaemia  appears  when  the  organisms  enter  the  cir- 
culation and  multiply  in  the  blood.  It  is  of  the  utmost  importance  to  realise  that 
suppuration  is  not  a  specific  process :  it  is  a  clinical  term  for  changes  which  can 
be  recognised  by  the  unaided  eye. 

The  character  of  the  pus  varies  considerably.  (1)  Thus  it  may  be  thick, 
creamy,  light  yellowish,  or  greenish  in  colour,  possessing  a  characteristic 
faint  odour  (laudable  pus,  which  is  oftenest  associated  with  staphylococci). 
(2)  It  may  be  serous  and  thin,  when  the  streptococcus  is  also  not 
uncommon.  (3)  Its  colour  may  be  blue  or  green,  due  to  the  presence 
of  the  B.  pyocyaneus.  (4)  In  typhoid  suppuration  the  pus  is  generally 
thick  and  reddish  in  colour,  (5)  while  gangrenous  pus  is  usually  associated 
with  a  mixture  of  organisms  (mixed  infection).  It  must  not  be  imagined, 
however,  that  it  is  possible  to  recognise  the  bacterial  infection  from  the 
appearance  or  character  of  the  pus,  which  can  only  be  gauged  by  means  of 
the  cultivation  tube,  all  the  more  since  usually  two  or  more  species  of 
pyogenetic  organisms  occur  together. 

A  suppurative  process  may  be  either  primary  or  secondary,  i.e.  it  may 
be  the  only  lesion  present,  or  it  may  appear  in  the  course  of  or  after  the 
defervescence  of  an  infective  fever.  Thus  an  abscess  may  be  due  to  some 
injury  followed  by  infection  (primary  suppuration);  another  may  occur 
during  or  after  an  attack  of  enteric  fever  (secondary  suppuration).  In  the 
latter  case  the  suppuration  may  be  due  to  the  organisms  which  caused  the 
fever,  B.  typhosus  (homologous  infection),  or  it  may  be  due  to  an  altogether 
different  organism,  a  streptococcus  or  a  staphylococcus  (heterologous  in- 
fection). 

Anatomically,  suppuration  may  be  superficial,  or  interstitial;  that 
is,  pus  may  either  be  discharged  from  a  free  surface  or  it  may  collect 
in  the  deep  tissues.  When  the  process  is  superficial,  it  may  appear  (a)  as 
a  result  of  inflammation  of  a  mucous  membrane, — pyorrhoea,  or  (b)  of  a 
serous  membrane, — empyema.  Pyorrhoea  may  or  may  not  be  accompanied 
by  superficial  ulceration.     The  term  empyema  is  now  generally  applied  to 


SUPPURA TION—H^MORRHA GIC  EXUDA TION. 


27 


suppuration  of  the  pleura.  In  interstitial  suppuration  the  pus  may 
remain  (1)  localised,  forming  an  abscess  which  may  or  may  not  be  sur- 
rounded by  a  capsule,  or  (2)  it  may  infiltrate  the  connective  tissues.  The 
purulent  infiltration,  by  destroying  the  tissues  bathed  by  the  pus,  may 
become  converted  into  an  abscess.  If  the  pus  infiltrates  the  epidermis, 
the  result  is  a  pustule,  which  in  reality  is  an  epidermal  abscess. 

Suppuration. 


1.  Superficial — 

(a)  Mucous  membrane  =  pyorrhoea 

±  ulceration. 

(b)  Serous  membrane  =  empyema. 


t  ±     j.  -±  •  7  f  Connective  tissue  = 
lnterstitial\        ,  ,  , 

^     abscess  ±  capsule. 

(a)  Localised :   Epidermis  =  pus- 

tule. 

(b)  Infiltrating :    may    become   an 

abscess. 


The  pus  which  has  been  formed  (if  small  in  amount)  may  be  reabsorbed 
on  cessation  of  the  irritation  of  inflammation.  This  is  effected  in  part  by 
phagocytosis,  in  part  by  the  proliferation  of  the  endothelial  and  connective 
tissue  cells.  Proliferative  changes  there  always  must  be,  because  during  sup- 
puration there  is  always  histolysis,  and  the  destroyed  tissue  must  be  replaced 
by  fibrous  tissue  (indirect  repair).  The  pus  may  remain  behind,  and  result 
in  the  formation  of  a  chronic  abscess,  which  may  have  a  distinct  fibrous 
capsule,  and  on  cessation  or  abatement  of  the  inflammation  the  capsule 
becomes  smooth,  and  forms  the  so-called  pyogenic  membrane  of  older 
writers.  In  most  chronic  abscesses  inflammation  and  suppuration  con- 
tinue, micro-organisms  flourish  in  the  pus,  and  they,  with  their  poisons,  act 
as  irritants.  In  some,  however,  all  inflammation  ceases,  the  micro-organ- 
isms perish,  symptoms  due  to  pent-up  pus  often  being  entirely  absent  (cold 
abscess).  On  the  other  hand,  the  unabsorbed  pus  may  become  curdy  and 
inspissated,  caseous,  or  even  calcareous  or  cretaceous,  as  the  result  of  a 
deposition  of  calcium  salts ;  calcification  is  always  preceded  by  inspissation 
or  caseation. 

Pus. 


Reabsorption. 


Retention. 


Liquid —  Inspissated — 

(a)  Chronic  abscess,   (a)  Curdy. 

(b)  Cold  abscess.         (b)  Caseous, 
(c)  Calcareous. 

Haemorrhagic  exudation. — Under  certain  conditions  the  diapedesis 
of  red  corpuscles  may  be  excessive,  the  exudation  becoming  hsemor- 
rhagic.  In  such  cases  leucocytes  are  generally  scarce;  there  is  a  blood- 
stained serous  exudation,  but  occasionally  the  red  corpuscles  are  mixed  with 
the  leucocytes  and  round  cells,  which  have  been  collected  in  large  numbers 
at  the  inflammatory  centre — blood-stained  purulent  exudation. 

The  excessive  diapedesis  of  the  red  corpuscles  is  due  mainly  to  the  activity  of 
the  irritant,  or  to  lowering  of  the  resisting  powers  of  the  tissues.  Virulent  infec- 
tions, such  as  smallpox,  malignant  pustules,  and  acute  necrosis,  are  frequently 
accompanied  by  haemorrhagic  exudation ;  whilst  in  a  debilitated  subject,  suffering 
from   renal  disease,  inflammations  readily  become  haemorrhagic.     In  gangrene, 


28 


GENERAL  PATHOLOGY  OF  DLSEASE. 


where  tile  toxines  are  powerful  and  absorbed  in  large  quantities,  the  vessels  are 
injured,  and  haemorrhages,  due  to  direct  rupture,  or  indirectly  to  diapedesis,  are 
common.  Again,  in  the  early  stages  of  acute  inflammation,  haemorrhagic  exuda- 
tions are  common ;  in  the  first  stages  of  acute  nephritis  the  urine  is  often  red  from 
admixture  of  blood  (nephritis  hsemorrhagica).  A  mechanical  injury  may  cause 
vascular  lesions,  gross  or  minute,  by  which  the  blood  finds  an  outlet  and  mixes 
with  the  inflammatory  exudation ;  this,  however,  is  a  true  haemorrhage,  and  is 
very  different  from  haemorrhagic  inflammation,  where  the  blood  transudes  by  a 
process  of  diapedesis ;  the  former  is  a  haemorrhage  per  rhexin,  the  latter  a 
haemorrhage  per  diapedesin.  Again,  inflammation  may  occur  in  a  part  the 
venous  circulation  of  which  is  laboured  and  obstructed,  i.e.  in  an  engorged  area. 
Here  there  is  considerable  slowing  of  the  blood  stream,  marked  fulness  of  the 
venous  channels,  and  grave  disturbance  of  nutrition. 


Haemorrhagic  Inflammation. 


(1)  Direct  haemorrhage  (2)  Indirect  haemorrhage 

{per  rhexin)  {per  diapedesin) 

=  lesion   of  vessel   wall,  gross  (a)  Intense  irritation. 

or  minute.  (b)  Early  stages  of   acute   in- 

flammation, 
(c)  Venous  engorgement. 
{d)  Loss    of   local    or    general 
tissue  resistance. 

The  proliferative  changes  of  acute  inflammation  are  best  seen  when  the 
exudative  changes  are  clearing  away,  but  it  is  erroneous  to  imagine  that  in 
point  of  time  they  follow  the  exudative  phenomena.  They  may  be 
observed  at  the  margins  of  the  affected  area,  even  at  the  earliest  stage  of 
inflammation,  but  they  become  more  evident  with  the  disappearance  of  the 
leucocytes ;  the  veil  is  lifted,  and  a  clear  view  is  obtained,  and  they  persist, 
passing  on  imperceptibly  to  play  a  part  in  the  stages  of  repair.  Repair  is 
not  necessarily  a  termination  of  inflammation,  but  proliferative  changes  are 
always  present.  An  injured  tissue  which  has  any  life  left,  is  always  ready 
to  react  by  repair ;  if  there  is  loss  of  substance,  the  living  cells  multiply 
and  proliferate;  if  there  is  no  loss  of  substance  and  no  necrosis,  but  merely 
damage  to  the  cell,  the  cell  itself  may  recover.  There  are,  therefore,  two 
processes  by  which  an  injury  is  made  good — {a)  recovery,  (&)  repair  by 
proliferation.  The  latter  may  or  may  not  be  accompanied  or  preceded  by 
inflammation.  Thus  an  injury  to  a  tissue  may  not  be  sufficient  to  cause 
proliferation  of  the  connective  tissue ;  repair  is  then  direct,  the  cells  pro- 
liferating and  producing  homologous  tissue ;  if,  however,  it  be  sufficient  to 
rouse  the  connective  tissue  to  inflammatory  reaction,  repair  is  indirect: 
matter  has  to  be  cleared  away,  the  resulting  gap  has  to  be  filled  up,  and  this 
can  only  be  done  by  fibrous  tissue,  i.e.  by  heterologous  tissue.  It  is  the  nature 
of  things  that  reparative  changes  should  appear  in  inflammation,  the  remain- 
ing living  tissue  tends  to  repair  an  injury ;  that  is  a  postulate  of  pathology. 
The  least  injured  cells  recover,  the  more  injured  ones  die,  but  their  places 
are  supplied  by  a  new  progeny.  Since  in  inflammation  there  is  always  some 
necrosis,  therefore  some  proliferation,  proliferative  changes  are  necessarily 
present  in  inflammation.  These  changes  are  observed — (1)  in  the  connective 
tissue  cells,  (2)  in  the  endothelial  cells  of  the  lymph  spaces  and  capillaries. 
The  connective  tissue  cells  enlarge ;  their  nuclei  become  swollen,  round,  or 
oval,  and  karyokinesis  (mitosis)   is   active;    this   is   certain   evidence  of 


REPAIR  BY  PR  O  LIFER  A  TION.  2  9 

proliferation.  The  leucocytic  infiltration  may  be  so  considerable  as  to  hide 
the  proliferative  phenomena  altogether,  but  as  .soon  as  the  leucocytic 
infiltration  clears  up,  which  it  always  does  as  the  inflammation  subsides, 
what  has  taken  place  may  be  clearly  seen.  There  are  many  large 
protoplasmic  cells,  rich  in  cell  substance,  and  with  nuclei  which  stain  but 
faintly,  or  are  rich  in  chromatin  and  resemble  epithelial  cells,  and  are  there- 
fore usually  spoken  of  as  epithelioid  cells.  Others  are  more  fusiform  in  shape, 
with  long  darkly  staining  nuclei ;  these  gradually  become  spindle-shaped. 
It  is  generally  believed  that  the  spindle  cells  are  merely  a  later  stage  of 
the  epithelioid  cells,  i.e.  that  both  are  derived  from  the  connective  tissue  cells, 
although  some  observers  maintain  that  the  spindle  cells  are  derived  from  the 
fixed  connective  tissue  cells,  and  the  epithelioid  cells  from  the  endothelium. 
At  this  period,  when  the  leucocytic  infiltration  has  disappeared  and  the  cells 
begin  to  proliferate,  numbers  of  small  uninuclear  round  cells  appear,  which 
possess  a  large  round  nucleus  and  resemble  lymph  corpuscles  (lymphocytes). 
These  small  cells  are  collected  in  irregular  groups  or  in  distinct  masses,  which 
may  be  compared  to  adenoid  or  lymphoid  collections,  and  they  constitute  the 
small  round-cell  infiltration  (lymphocytic  infiltration).  These  small  cells 
appear  to  be  derived  from  rapidly  proliferating  connective  tissue  cells,  from 
the  endothelium  of  the  lymphatic  spaces,  and  from  the  lymphocytes  which 
are  always  present  in  the  connective  tissue ;  but  many  of  them  may  have 
been  attracted  by  so-called  "  chemio tactic  "  influences.  The  free  connective 
tissue  cells,  the  lymphocytes,  and  the  endothelium  of  the  lymph  spaces  are 
all  migrating,  and  may  therefore  be  attracted  to  the  seat  of  irritation. 

The  normal  connective  tissue  possesses  (a)  fixed  cells  and  (b)  wandering  cells ; 
but  while  only  the  latter  are  free  and  under  the  spell  of  chemiotaxis  normally 
during  inflammation,  the  fixed  cells,  as  they  divide  and  proliferate,  may  become 
free  and  wandering.  Migrating  to  the  seat  of  inflammation,  they  are  at  first 
mixed  up  with  the  emigrated  leucocytes  in  the  exudation,  and  assist  the  latter  in 
clearing  away  the  irritant,  foreign  and  dead  matter,  haemorrhages  and  fibrin ; 
they  also  take  up  the  remains  of  dead  leucocytes,  which  have  done  their  share  of 
the  work,  and  thus  complete  the  cleansing  process.  When  everything  is  cleared 
away,  they  either  fall  into  their  proper  places,  or  they  undergo  further  changes 
and  form  vascular  cicatricial  tissue.  A  croupous  pneumonia,  for  instance,  may 
clear  up,  the  leucocytes  disappearing,  being  in  part  discharged  with  the  expectora- 
tion, in  part  taken  up  by  the  connective  tissue  cells  and  the  endothelium;  these 
cells  may  then  simply  resume  the  places  they  ought  to  occupy,  so  that  the  result 
is  a  complete  resolution  without  secondary  thickening,  or  they  may  form  vascular 
connective  tissue,  which  gradually  becomes  fibrous  and  leads  to  a  chronic  indura- 
tion of  the  lung.  Eesolution  then  corresponds  to  homologous  repair,  induration  to 
heterologous  repair  (cicatrisation).  When  cicatrisation  occurs,  the  proliferated 
cells  become  spindle-shaped,  arrange  themselves  in  strands  along  the  vessels, 
more  and  more  interstitial  substance  appears  between  the  cells,  which  have  become 
still  more  fusiform,  and  are  now  called  fibroblasts.  The  latter  become  gradually 
less  protoplasmic,  while  the  interstitial  substance  increases,  and  gradually  typical 
fibrous  tissue  is  formed,  which  in  time  becomes  harder  and  less  vascular. 

It  is  during  the  earlier  stages  of  repair  that  phagocytosis  is  best  seen.  The 
connective  tissue  cells  take  up  the  dead  tissues,  leucocytes,  foreign  bodies, 
etc.,  following  the  example  set  them  by  the  leucocytes.  If  the  material  to  he 
removed  is  copious  or  firm,  giant  cells — multinucleated  cells  with  numerous  nuclei, 
and  often  provided  with  branched  processes — appear.  They  are  both  phagocytic 
and  histolytic,  devouring  and  dissolving  the  substances  with  which  they  come  in 
contact. 

During  the  process  of   heterologous  repair  new  vessels  appear.     These  are 


3° 


GENERAL  PATHOLOGY  OF  DISEASE. 


formed  from  the  original  vessels,  which  throw  out  endothelial  huds  into  the 
inflammatory  area  occupied  by  the  proliferated  cells,  i.e.  by  the  small  round  cells 
forming  the  lymphocytic  infiltration.  At  a  given  point  the  endothelial  cells 
divide  and  multiply,  until  a  solid  endothelial  protrusion  is  formed.  This  becomes 
hollowed  out,  the  blood  extending  into  it  from  the  old  vessel.  These  newly 
formed  vessels  are  surrounded  by  numerous  small  round  cells,  amongst 
which  are  spindle  cells,  epithelioid  cells,  and  large  protoplasmic  cells,  and,  under 
the  above-mentioned  conditions,  giant  cells.  Such  vascularised  proliferating 
cellular  tissue  constitutes  the  so-called  granulation  tissue  of  the  surgeon, 
which  gradually  becomes  converted  into  cicatricial  tissue.  As  the  cicatricial 
tissue  becomes  more  fibrous,  the  vessels  gradually  disappear,  and  a  hard,  dense, 
white  or  glistening  fibrous  tissue  remains. 

It  should  be  remembered  that  as  soon  as  resolution  or  repair  sets  in, 
inflammation  is  at  an  end,  and  further  that  cicatrisation  may  take  place 
without  the  occurrence  of  preceding  inflammation. 

Abscess  and  ulceration. — Of  the  clinical  results  of  inflammation, 
abscesses  and  ulcers  require  special  mention.  Abscess  is  a  local  collec- 
tion of  retained  or  pent-up  pus,  buried  in  the  depth  of  the  tissues. 
If  the  early  leucocytic  infiltration  is  excessive,  the  inflammatory 
exudation  assumes  the  characters  of  pus,  being  whitish  in  colour,  when 
enough  pus  is  formed  to  be  detected  with  the  unaided  eye.  The  newly 
formed  pus,  acting  destructively  on  the  surrounding  tissue,  assists  the 
original  irritant.  The  inflammation  thus  progresses,  more  leucocytes  are 
attracted,  and  the  proliferating  tissue  and  endothelial  cells  are  compelled 
to  withdraw,  being  destroyed  by  the  spreading  suppuration.  A  growing 
collection  of  pus  is  thus  pent  up  in  the  tissues,  and  an  acute  abscess  is  the 
result. 

Should  the  process  last  for  some  time,  or  the  irritant  be  abated,  the 
proliferating  cells  may  gain  the  upper  hand,  and  the  granulation  tissue, 
which  may  eventually  become  changed  into  fibrous  tissue,  is  formed :  the 
collection  of  pus  is  thus  enclosed  by  a  fibrous  membrane, — a  pyogenetic 
membrane.  There  may  be  all  gradations  of  structure  in  this  wall  from  a 
fibrous  membrane  to  soft  granulation  tissue.  In  the  latter  case  the 
granulations  continue  to  discharge  pus,  and  the  abscess  grows ;  where  a 
typical  fibrous  membrane  is  present,  pus  formation  has  ceased. 

An  ulcer,  when  acute,  is  merely  an  inflamed  and  suppurating  surface  of  the 
skin  or  mucous  membrane,  accompanied  by,  or  resulting  from,  necrosis.  Necrosis, 
whether  caused  by  inflammation  or  by  any  other  cause,  implies  loss  of  substance, 
a  loss  that  has  to  be  made  good.  Inflammation  follows  upon  necrosis,  if  it  did 
not  exist  before,  and  as  recovery  takes  place  gradually,  the  proliferative  changes 
become  more  and  more  apparent,  the  necrotic  tissue  being  dissolved  and  absorbed, 
and  granulation  tissue  developed.  So  long  as  the  slough  and  the  irritant  cause 
remain,  the  granulation  will  discharge  pus,  but  gradually,  as  the  slough  is  cast  off, 
the  discharge  of  pus  ceases,  the  granulations  become  fibrous  tissue,  and  the 
cutaneous  or  mucous  surface  is  restored.  An  ulcer  may  therefore  be  compared  to 
an  open  abscess ;  both  when  of  some  standing  being  lined  by  granulations,  and 
when  acute  being  marked  off  by  typical  inflammatory  tissue.  The  necrosed 
tissue  may  show  itself  either  as  a  coherent  piece  of  dead  tissue,  a  slough,  or  as  a 
friable  structureless  mass. 

Septicaemia  and  pysemia. — Of  the  complications  of  inflammation  the 
most  interesting,  if  not  the  most  important  perhaps,  are  septicaemia  and 
secondary  infections.  The  commonest  causes  of  inflammation,  as  already 
seen,  are   micro-organisms,  and   the   complications   here   considered   are 


SEPTICEMIA  AND  PYEMIA.  31 

closely  bound  up  with  the  fate  of  these  micro-organisms  in  the 
tissues.  Whether  one  of  the  pyococci,  or  a  specific  bacillus  such  as 
the  bacillus  of  typhoid  fever,  diphtheria,  or  tuberculosis,  caused  the 
initial  inflammatory  lesion,  their  future  is  governed  by  the  most  diverse 
circumstances. 

1.  They  may  remain  localised  at  the  seat  of  infection,  where  they 
produce  simple  inflammation,  or  its  various  modifications.  Here 
they  may  soon  perish,  the  phenomena  of  inflammation  coming  to  an 
end,  or  they  may  be  pent  up  or  retained,  together  with  some  of  the 
inflammatory  products,  and  acting  as  a  continual  irritant,  a  chronic 
suppuration  results.  This  leads  to  chronic  abscess  and  chronic  ulcera- 
tion. The  micro-organisms  continually  irritate  the  imperfectly  formed, 
immature,  and  delicate,  vascular,  connective  tissue,  and  the  inflam- 
matory exudation,  generally  in  the  form  of  pus,  persists.  The 
micro-organisms,  growing  quietly  and  undisturbed,  produce  their  poisons 
or  toxines,  which  being  absorbed  lead  to  chronic  intoxication  (toxcemia),  the 
effect  of  which  may  show  itself  as  fever  of  a  remittent,  intermittent,  or 
hectic  type.  Thus,  where  there  are  abscesses  hidden  in  the  tissues,  as  for 
instance  in  the  lung  or  liver,  the  thermometer  often  reveals  the  existence 
of  a  suppurative  fever ;  the  same  type  of  fever  occurs  with  typhoid  ulcers 
and  with  tuberculous  lesions. 

2.  On- the  other  hand,  the  organisms  may  not  remain  localised,  but 
may  be  carried  away  from  the  primary  seat  of  lesion.  The  paths  by  which 
they  travel  may  be  (a)  either  the  lymphatics,  (b)  or  the  blood  vessels. 
The  pathogenetic  organisms  being  mostly  parasitic,  i.e.  capable  of  thriving 
in  or  on  living  tissues,  may  travel  along  the  lymph  channels  into  the 
surrounding  tissues,  and  form  fresh  foci  of  inflammation  or  suppuration 
at  some  distance  from  the  primary  area  (secondary  infections).  Thus,  in 
croupous  pneumonia,  the  pneumococcus  may  be  carried  into  the  pleura,  the 
pericardium,  or  the  peritoneum,  by  the  lymph  chrrrels,  and  there  produce 
inflammatory  changes.  Again,  the  lymphatics  m«,y  transfer  them  to  the 
nearest  lymphatic  glands,  which  in  turn  become  inflamed  or  form  fresh 
foci  of  infection.  Thus,  in  typhoid  fever,  bacilli  are  carried  to  the 
mesenteric  glands,  or,  again,  streptococci,  with  or  without  diphtheria  bacilli, 
find  their  way  into  the  cervical  or  bronchial  glands  during  an  attack  of 
diphtheria,  or  suppurating  glands  may  appear  in  the  groin  as  a  sequela  to 
an  ulcer  in  the  foot.  In  such  cases  the  symptoms  may  be  those  of  a  serious 
and  severe  intoxication;  the  foci  whence  poison  may  be  absorbed  being  or 
becoming  numerous  and  extensive.  An  infected  lymphatic  gland  may 
become  the  source  of  a  general  infection,  if  a  communication  is  established 
between  it  and  the  blood  circulation  through  the  thoracic  duct.  Thus 
Weigert  has  demonstrated  that  in  acute  miliary  tuberculosis  the  thoracic 
duct  is  frequently  tuberculous,  and  by  this  path  the  tubercle  bacilli  reach 
the  systemic  circulation.  They  may  then  be  carried  away  as  bacterial 
emboli  into  distant  parts,  or  they  may  multiply  in  the  circulation, 
producing  a  hsemic  infection.  It  is  a  curious  fact  that  most  morbid 
anatomists  are  satisfied  in  cases  of  acute  miliary  tuberculosis  when  they 
are  able  to  demonstrate  a  caseous  focus  somewhere  in  the  body,  but  they 
do  not  attempt  to  find  the  actual  point  of  entrance  into  the  systemic 
circulation. 

The  diffusion  of  the  organisms  which  are  responsible  for  the  primary  infection 
may,  however,  be  brought  about  by  the  blood  vessels.  Here  two  methods  of 
dissemination  must  be  distinguished. 


32  GENERAL  PATHOLOGY  OF  DISEASE. 

(1)  The  venous  channels  being  eroded  or  laid  open  during  and  by  the 
process  of  histolysis,  a  few  microbes  may  find  an  entrance  into  the  blood 
stream,  and  then  one  of  several  things  may  happen. 

(a)  The  blood  may  possess  sufficiently  strong  bactericidal  power  to  cope  with  and 
destroy  the  few  organisms  which  have  found  their  way  into  the  vessel.  This  is 
the  most  fortunate  termination  of  what  might  be  a  serious  accident,  for  no  evil 
will  come  of  this  hsemic  invasion ;  (b)  the  micro-organisms  may  escape  the  deadly 
action  of  the  blood,  and,  without  multiplying  in  the  circulation,  they  may  be  carried 
away  as  emboli  through  the  heart  into  the  systemic,  pulmonary,  or  portal 
circulation,  till  arrested  at  some  narrow  point.  Here,  if  suitable  conditions  exist, 
they  will  gain  a  footing  and  form  a  fresh  focus  of  inflammation  or  infection,  i.e. 
a  metastatic  or  secondary  focus,  due  to  the  arrest  of  a  bacterial  embolus,  is  formed. 
If  conditions  at  the  point  of  arrest  are  not  suitable,  the  micro-organisms  may 
perish,  but  they  may  remain  latent,  and  survive,  inoffensive  and  harmless,  until 
such  conditions  arise  as  will  awaken  them  into  dangerous  activity.  Thus,  in 
typhoid  fever,  organisms  are  almost  constantly  found  after  death  in  the  bone 
marrow ;  there  they  have  been  carried  from  the  seat  of  ulceration  to  the  blood 
and  through  the  heart.  Here  they  enjoy  an  existence  of  inactivity,  till  perhaps 
an  injury  to  the  bone  or  a  general  tissue  depression  resuscitates  them  into 
aggressive  virulence,  (c)  The  micro-organisms  may  find  the  blood  so  impoverished 
that  its  bactericidal  power  has  vanished,  and  they  may  then  multiply  in  the 
circulation,  and  produce  a  general  hsemic  infection,  —  a  septicaemia.  In 
septicaemia,  micro-organisms  are  found  in  the  circulation,  where  they  multiply 
and  thrive,  and  produce  their  poisons.  ^Nothing  should  or  must  be  called 
septicaemia,  unless  there  be  general  hseniic  infection  (demonstrated  by  cultivation), 
whatever  may  be  the  clinical  prejudice.  Any  inflammatory  infection  may  end  in  this 
untoward  manner,  e.g.  pneumonia,  typhoid  fever,  sore  throats,  acute  necrosis, 
erysipelas,  cellulitis.  When  symptoms  point  to  serious  complications,  a  thorough 
examination  of  the  blood  for  hseniic  infection  renders  it  possible  to  pronounce 
upon  a  most  serious  prognosis,  and,  in  these  days  of  serum  therapeutics,  to  adopt 
appropriate  treatment. 

A  general  hsemic  infection  may,  however,  start  in  a  roundabout  way.  A 
bacterial  embolus  may  enter  a  venous  channel,  and  may  find  its  resting  place  on 
one  of  the  cardiac  valves,  where,  should  the  organisms  find  the  conditions  necessary 
for  their  growth,  an  infective  endocarditis  must  result.  From  the  infected  valve 
micro-organisms  may  be  poured  into  the  circulation,  till  the  hsemic  infection  is 
complete.  Again,  a  metastatic  focus,  produced  in  the  following  manner,  may 
become  the  starting-point  of  a  hsemic  infection,  or  an  infective  endocarditis  which 
generally  implies  hsemic  infection. 

Infected  fibrinous  or  tissue  emboli  may  take  the  place  of  simple 
bacterial  emboli.  The  veins  at  the  seat  of  inflammation  become  plugged 
with  fibrin,  the  thrombus  is  invaded  by  micro-organisms,  and  thus 
become  infected.  From  this  infected  and  contaminated  mass,  fragments 
may  be  carried  off  by  the  blood  current  to  the  right  side  of  the  heart, 
where  they  may  become  attached  to  the  tricuspid  valve  and  form  the 
starting-point  of  an  infective  endocarditis.  If  not  arrested  there,  the 
embolus  is  carried  into  the  lung,  and  may  become  lodged  in  some  arterial 
branch,  producing  an  infected  infarct.  The  embolus  may,  however,  be 
carried  right  through  the  lung  into  the  left  ventricle,  and  thence  may 
enter  the  aorta  and  the  systemic  circulation,  or  it  may  become  fixed  on 
the  mitral  valve.  It  is  natural  that,  when  an  infective  endocarditis 
appears,  micro-organisms  will  readily  find  their  way  into  the  general 
circulation,  and  from  the  diseased  valve  bacterial  or  infected  fibrinous 
emboli  may  enter   the   circulation   and  produce  fresh  metastatic  foci  or 


SEPTIC  INFECTION  AND  INTOXICATION 


33 


general  haemic  infection.  It  stands  to  reason  that  the  presence  of 
metastatic  abscesses,  clinically  called  pyaemia,  does  not  of  necessity 
imply  that  micro-organisms  are  found  in  the  blood,  that  is,  that 
there  is  septicaemia.  (2)  The  micro-organisms  may  be  carried  away 
from  the  seat  of  lesion  by  the  arterial  channels.  A  small  artery,  for 
instance,  although  the  elastic  coat  is  very  resistant  against  infection  of 
any  kind,  may  be  attacked  and  pierced  by  the  micro-organisms,  which 
are  then  carried  away  as  bacterial  emboli  towards  and  into  the  capillary 
area. 

In  septicaemia  an  inflamed  area  becomes  invaded  by  saprophytic  and 
putrefactive  organisms.  These  latter  thrive  on  dead  or  dying  tissues,  but 
cannot  grow  on  healthy  or  living  tissues ;  saprsemia,  therefore,  commonly 
accompanies  gangrenous  or  ulcerated  lesions  ;  and  in  childbed,  with  which 
there  is  much  necrosis,  the  microbes  produce  their  toxines,  which  are 
absorbed,  and  serious  symptoms  of  sapraemia  may  result.  When  the 
necrotic  area  is  removed,  the  bacteria,  which  cannot  grow  in  living  tissues, 
disappear;  the  symptoms  of  sapraemia  subside,  and  the  patient  usually 
makes  a  speedy  recovery.  Septicaemia,  or  haemic  infection,  can  obviously 
never  be  produced  by  true  saprophytes.  In  the  following  table  are 
tabulated  the  various  paths  of  dissemination  : — 


Infection    of    an   ulcerating   or 
necrotic   area  by  saprophytic  I 
organisms,     accompanied    by  >- 
general      intoxication,     with 
their  products. 


Recovery  after  radical  removal, 

Saprcemia.     -I      so   long   as    the    amount    of 

toxines  absorbed  are  sublethal. 


Infection    of    an    inflammatory^ 
area  by  parasitic    organisms, 
accompanied    by   general   in- 
toxication,   with    their    pro- 
ducts. 


Septic 

Infection, 

and 

Intoxication. 


f Lymphatic  infection,  direct  re- 
tention    (cellulitis) ;    glands 
(buboes),  septicaemia  ;  thora- 
cic duct,  multiple  emboli. 
Hsemic  infection  =  septicaemia. 

{Metastatic  in- 
fection (py- 
semia) ;  hae- 
mic  infec- 
tion. 
fMetastatic  in- 


Infected    fibrin 


I. 


ous  emboli      1  .  N     vPT 

[_     aemia). 


To  give  a  few  examples.  In  suppurative  otitis  media,  the  pyococcal  infection 
may  remain  localised  or  may  spread  to  the  brain,  leading  to  a  temporo-sphenoidal 
or  cerebellar  abscess,  or  it  may  spread  into  the  lateral  sinus  or  into  the  jugular 
vein,  and  thence  into  the  right  side  of  the  heart,  producing  an  infective 
endocarditis  and  general  haemic  infection  (septicaemia).  This  may  be  accompanied, 
or  followed,  by  multiple  embolism,  with,  metastatic  deposits  in  the  lungs,  spleen, 
and  elsewhere  (pyaemia). 

In  a  case  of  typhoid  fever  with  ulceration  in  the  intestines,  and  in  the  ulcers 
besides  the  typhoid  bacilli  there  are  streptococci  which  may  be  swept  away  by 
the  blood  stream,  and  deposited  in  the  bone  marrow,  where,  under  suitable 
conditions,  they  may  produce  a  secondary  lesion,  an  osteomyelitis.  On  the  other 
hand,  entering  the  blood  stream  they  may  multiply,  and  set  up  a  general  haemic 
infection  or  a  septicaemia,  in  some  rare  cases  with  infective  endocarditis,  and 
secondary  deposits  in  the  body  (pyaemia).  Even  the  typhoid  bacilli  themselves 
vol.  i. — 3 


34  GENERAL  PA THOL OGY  OF  DISEA SE. 

may  be  carried  away  by  the  blood  stream,  whence  they  may  be  thrown  out  in 
the  urine,  or  they  may  be  stored  up  in  the  bone  marrow.  There,  under  pro- 
vocation, they  may  produce  a  typhoidal  osteomyelitis.  Rarely  they  may  multiply 
in  the  blood,  and  give  rise  to  a  true  typhoidal  septicaemia.  In  croupous  pneumonia 
similar  processes  may  be  noted;  the  pneumococci  may  extend  locally  into  the 
pleura  or  pericardium,  the  effect  of  such  extension  being  a  pleurisy  or  peri- 
carditis ;  again,  in  endocarditis,  a  few  cocci  may  be  carried  away  by  the  blood 
into  the  meninges  without  the  blood  itself  becoming  infected ;  or  a  hsemic  infection 
may  occur  directly  from  the  lungs  or  indirectly  through  the  endocarditis.  In  the 
latter  case  pneumococci  will  be  found  in  the  blood,  and  there  may  be  multiple 
metastatic  foci  of  a  suppurative  nature. 

As  regards  the  anatomical  distribution  of  tlie  metastatic  or  pyazmic 
foci,  even  a  casual  observer  will  notice  that  when  the  primary  focus  is  in 
the  area  of  the  pulmonary  or  the  systemic  circulation  the  liver  generally 
escapes  the  metastatic  dissemination.  If  a  pulmonary  infective  lesion  is 
followed  by  pyaemia,  metastatic  deposits  occur  mainly  in  the  systemic,  but 
frequently  also  in  the  pulmonary  vascular  area;  if  a  systemic  infective 
lesion  is  followed  by  pyaemia,  metastatic  deposits  are  found  mainly  in  the 
pulmonary,  but  frequently  also  in  the  systemic  vascular  area.  Pyaemic 
deposit  in  the  liver  (portal  pyaemia)  is  often  observed  in  the  post-mortem 
room  ;  the  primary  focus  in  such  cases  is  always  in  the  portal  area.  An 
embolus  is  carried  up  by  a  venous  radicle  of  the  large  or  small  intestine, 
and,  entering  the  portal  vein,  is  finally  arrested  in  the  terminal  distribution 
of  this  vein.  Such  a  primary  portal  focus,  however,  may  also  produce  a 
metastatic  deposit  in  either  the  systemic  or  the  pulmonary  vascular  area.  A 
minute  bacterial  embolus  may  pass  through  the  entire  portal  zone  into 
the  vena  cava,  and  thence  into  the  right  side  of  the  heart,  to  be  deposited 
in  the  lungs  or  in  the  systemic  peripheral  area.  Similarly,  an  embolus 
may  be  carried  through  the  systemic  circulation  into  the  liver. 

The  following  table  will  serve  to  summarise  these  considerations : — 

Primary  Focus.  Metastatic  Deposits. 

-n  ,  f  Systemic  area. 

Pulmonary  area       ......-{,-£,  N 

J  ((Pulmonary  area.) 

o  .  f  Pulmonary  area. 

bystemic  area  .         .         .         .         .  -{  /c,     ,      .  J        x 

J  ((Systemic  area.) 

f  Portal  area. 

Portal  area      .......     \  (Pulmonary  area.) 

[(Systemic  area.) 

General  haemic  infection  may  owe  its  origin  to  a  primary  focus 
situated  anywhere,  whether  in  the  pulmonary,  systemic,  or  portal  area; 
and  when  a  general  septicaemia  has  developed,  metastatic  deposits  may 
appear  in  any  region  of  the  blood  vascular  system,  because  the  arteries 
may  carry  the  organisms  indiscriminately  over  the  body. 

Septicaemia  may  occur  without  any  recognisable  local  infection,  i.e. 
idiopathic  or,  better,  cryptogenetic  septicaemia.  No  primary  focus  is 
found,  yet  pathogenetic  bacteria  are  found  in  the  blood  and  organs.  These 
organisms  must  have  obtained  access  to  the  blood  from  the  respiratory  or 
alimentary  tract  or  from  the  skin,  parts  always  in  contact  with  bacteria. 
A  slight  loss  of  substance,  such  as  an  abrasion,  is  sufficient  to  open  up  the 
way,  whilst  it  must  also  be  remembered  that  the  adenoid  structures  of 
mucous  membranes  are,  even  in  the  normal  state,  but  scantily  and  incom- 
pletely covered   by  epithelium.     A  minute  superficial  lesion  may  easily 


CHRONIC  INFLAMMATION.  35 

escape  detection,  when  methods  are  used  which,  if  the  size  of  a  micro- 
organism be  considered,  are  very  coarse  indeed. 

Chkonic  Inflammation. 

The  term  chronic  inflammation  covers  processes  which  are  essentially 
different,  namely,  chronic  fibrous  changes,  chronic  catarrhal  conditions,  and 
chronic  suppuration.  When  pus  is  continually  discharged,  whether  it  be 
from  an  open  ulcer  or  a  closed  abscess,  or  a  large  area  healing  by  so-called 
second  or  third  intention,  there  is  always  a  granulating  surface.  In  such  pro- 
cesses, which  is  chronic,  the  discharge  or  the  inflammation  ?  Undoubtedly 
the  purulent  discharge.  Granulations  are  made  up  of  extremely  delicate, 
vascular,  undeveloped  connective  tissue,  which  is  easily  irritated,  becomes  in- 
flamed and  suppurates,  and  as  new  granulations  spring  up,  they  again  become 
inflamed  and  suppurate ;  or  if  the  irritation,  inflammation,  and  suppuration 
persist,  more  of  the  surrounding  healthy  tissue  is  attacked,  and  it  in  turn 
becomes  inflamed  and  suppurates.  Hence  the  irritation,  acting  ever  on 
fresh  tissues,  sets  up  an  ever  repeated  process  of  acute  inflammation,  affect- 
ing always  different  parts,  or  destroying  one  part  and  then  attacking  a  fresh 
part,  i.e.  there  is  chronic  irritation  continually  provoking  inflammation, 
and  producing  a  lasting  suppuration  of  an  ever-changing  surface.  The 
suppuration  of  these  numberless  foci  of  inflammation  amounts  to  chronic 
suppuration ;  it  is  only  observed  where  there  is  granulation  tissue.  From 
the  pathological  point  of  view  this  is  not  chronic  inflammation,  but 
chronic  irritation  of  such  intensity  as  to  produce  suppurative  inflammation 
of  the  delicate  granulation  tissue  as  it  appears,  or  to  destroy  the  superficial 
granulations,  and  to  act  on  the  freshly  exposed  tissues.  The  irritation  is 
the  constant  quantity,  but  the  suppurating  surface  changes.  Removal  of  the 
irritant  under  suitable  conditions  will  at  once  allow  the  granulations  to 
advance  to  cicatrisation.  In  this  country,  therefore,  continued  suppura- 
tion, or  a  continued  ulceration,  or  a  hidden  and  lasting  abscess,  are  not  as 
a  rule  regarded  as  chronic  inflammation. 

Histologically,  the  various  forms  of  so-called  chronic  inflammatory 
processes  may  be  classified  under  several  headings : — (1)  In  some  there  is 
hyperplasia  or  proliferation  of  the  connective  tissue ;  or,  if  a  mucous 
membrane  be  affected,  a  hyperplasia  both  of  the  epithelium  and  under- 
lying tissues,  in  which  sometimes  the  glands  also  share ;  (2)  in  others, 
so-called  catarrhal  conditions,  when  the  lesion  occurs  in  a  secreting 
tissue ;  (3)  or  an  interstitial  fibrous  change  ;  and  (4),  finally,  in  others  a 
complete  replacement  of  the  primary  elements  by  fibrous  tissue. 

In  chronic  inflammation  of  the  vocal  cords,  there  may  be  noticed 
chiefly — (a)  proliferation  and  hyperplasia  of  the  subepithelial  connective 
tissue,  i.e.  fibrous  hyperplasia,  or,  in  more  modern  language,  fibrosis ; 
(b)  proliferation  and  hyperplasia  of  the  epithelium  itself,  which  frequently 
becomes  horny ;  and  (c)  proliferation  of  the  capillaries  and  vascular 
elements.  The  proliferation  may  be  so  complete  and  uniform  as  to  lead 
to  a  papillomatous  growth  or  a  pachydermia. 

Compare  and  contrast  with  this  chronic  cervical  catarrh,  in  which  similarly 
there  are — (a)  proliferation  and  hyperplasia  of  the  subepithelial  connective 
tissue;  (b)  proliferation  and  hyperplasia  of  the  secreting  epithelium  itself, 
leading  to  dilated  and  elongated,  or  even  cystic  follicles,  lined  often  by  several 
layers  of  columnar  epithelium ;  and  (c)  proliferation  of  the  capillaries  and  smaller 
vessels.     Here  the  proliferation  may  he  so  complete  and  uniform  as  to  lead  to  a 


3 6  GENERAL  PA THOL OGY  OF  DISEASE. 

beautifully  papillomatous  surface.  The  proliferated  epithelium  retains  its- 
secretory  activity,  hence  the  catarrhal  flow.  This  is  the  only  apparent  difference 
between  this  affection  and  the  laryngeal  form ;  the  squamous  epithelium  is  not 
secretory  in  the  ordinary  sense  of  the  term,  and  there  is  no  catarrhal  flow.  In 
one  case  the  catarrhal  flow,  in  the  other  increased  formation  of  horny  substance, 
mark  the  increased  functional  activity.  In  point  of  principle,  there  is  no 
difference  between  these  two  processes,  which  at  first  sight  appear  to  be  distinct ; 
and  therefore  to  the  three  factors  mentioned,  namely,  hyperplasia  of  the  connective 
tissue,  hyperplasia  of  the  epithelium,  and  slowly  increasing  vascularity,  a  fourth 
must  be  added,  namely,  increased  functional  activity.  These  changes  are 
frequently,  if  not  commonly,  found  in  so-called  chronic  inflammation  of  mucous, 
muco-cutaneous,  or  cutaneous  surfaces.  But  in  the  fibrous  changes  only  is 
"fibrosis"  an  essential  attribute  of  chronic  inflammation. 

In  some  cases,  in  place  of  hyperplasia,  there  is  atrophy  of  the  mucosa,  as 
in  atrophic  rhinitis  or  gastritis.  During  certain  stages,  at  least,  firm  fibrous 
tissue  is  formed,  contracting  from  the  surface,  and,  so  to  speak,  smothering  the 
glands.  These  for  a  long  time  remain  functionally  very  active — teste  the  foetid 
secretion  of  ozsena,  or  the  cystic  dilatation  of  the  glands  in  atrophic  gastritis. 
Instead  of  a  hyperplasia,  there  is  an  induration  of  the  connective  tissue,  without 
proliferation  of  the  surface  epithelium  or  the  capillaries.  This  induration 
could  not  have  occurred  without  previous  proliferation,  the  newly-formed  fibrous 
tissue  becoming  condensed  as  soon  as  it  is  formed;  it  required  a  proliferative 
stimulus  for  induration  or  sclerosis  to  ensue. 

Why  do  some  newly  formed  fibrous  tissues  contract  and  others  go  on 
increasing?  A  scar  will  generally  condense  into  hard  fibrous  tissue,  but 
occasionally  it  becomes  cheloid.  G-rawitz  lays  it  down  that  the  connective 
tissue  "  having  once  awakened,"  there  is  no  limit,  necessarily,  to  the  energy  of 
its  waking  hours ;  it  may  go  on  unchecked,  in  a  condition  of  morbid  insomnia, 
but  it  usually  stops  at  a  certain  point,  where  it  may  cease,  or  the  tissue  may 
become  condensed,  hard,  or  indurated.  It  must  further  be  remembered  that 
atrophy  and  polypoid  hypertrophy  (in  the  stomach,  for  instance)  may  occur 
together.  Again,  epithelial  proliferation  is  frequently  present  in  atrophic 
"  inflammations" ;  in  ozsena  the  stinking  mucosa  may  be  lined  by  several  layers 
of  squamous  epithelium,  the  product  of  a  proliferative  metaplasia,  and  papillo- 
matous cysts  occur  in  atrophic  gastritis.  So  that  even  in  these  conditions  three 
of  the  four  above-mentioned  factors  are  present,  although  in  modified  form, 
namely — (1)  induration  of  the  subepithelial  connective  tissue;  (2)  partial  or 
complete  proliferation  of  the  epithelium;  and  (3)  increased,  though  altered, 
functional  activity,  the  increased  vascularity  being  impossible  on  account  of  the 
induration. 

Chronic  inflammation  of  the  serous  membranes  is  characterised  by  either  mere 
opacity  or  by  thickening  with  or  without  contraction,  i.e.  fibrous  hyperplasia  with 
or  without  induration.  There  may  also  be  distinct  hyperplasia  of  the  epithelium 
(or  endothelium),  which  may  even  become  converted  into  a  kind  of  squamous 
epithelium.  Increased  vascularity  is  often  present,  and  with  this  hydrops  is 
frequently  associated,  which  followers  of  Heidenhain  would  be  inclined  to  regard 
as  due  to  an  increased  functional  activity  of  the  endothelium.  Here,  then,  all 
the  four  factors  may  be  present,  but  the  fibrous  changes  always. 

When  the  lesions  of  chronic  interstitial  inflammation,  e.g.  interstitial 
nephritis,  cirrhosis  of  the  liver,  interstitial  myositis  and  myocarditis,  are  examined 
microscopically,  the  most  striking  feature  is  the  marked  fibrosis  which  has  taken 
place — fibrous  tissue,  more  or  less  well  formed,  and  often  of  exceeding  firmness, 
surrounds  the  active  or  organic  structures,  whether  they  be  kidney  tubules,  liver 
cells,  or  muscle  fibres ;  the  framework  or  secondary  elements  may  altogether  out- 
grow the  primary  elements.  Increased  vascularity  is  often  present,  but  may  be 
absent  in  advanced  stages ;  a  hyperplasia  of  the  epithelial  tissues  cannot  of  course 
take  place  in  myocarditis  or  myositis ;  but  in  the  interstitial  forms  of  chronic 


IS  CHRONIC  INFLAMMATION  AN  INFLAMMATION!       37 

inflammation  it  is  generally  absent,  even  in  organs  which  are  largely  epithelial  in 
structure,  such  as  the  kidney,  liver,  and  pancreas.  In  an  interstitial  nephritis  the 
renal  epithelial  substances  become  compressed  and  atrophied,  the  liver  cells 
degenerate  and  disappear  extensively  in  most  forms  of  cirrhosis,  and  the  pan- 
creatic cells  share  the  same  fate. 

As  the  acute  inflammation,  the  result  of  bacterial  irritation,  passes  off,  if  it 
has  caused  no  serious  lesion  to  the  muscle  fibres  themselves,  practically  no 
permanent  change  may  be  left  behind.  If,  however,  the  acute  injury  has  caused 
serious  lesion,  breaking  up  some  of  the  muscle  fibres,  or  producing  partial  or  total 
necrosis,  then  repair  is  accompanied  by  formation  of  fibrous  tissue,  and  the 
foundation  for  a  fibrous  hyperplasia  is  laid.  This  newly  formed  fibrous  tissue,, 
■endowed  with  the  progressive  stimulus  characteristic  of  all  infant  growth,  may 
extend  beyond  the  original  seat  of  lesion,  between  the  sound  muscle  fibres,  so 
that  on  transverse  section  at  this  stage  small  and  compressed  muscle  areas, 
surrounded  by  rings  of  fibrous  tissue,  are  seen,  —  "chronic  interstitial 
myositis."  The  effect  of  this  compressing  fibrous  tissue  is  to  cause  further 
degeneration  of  the  muscle  fibres,  and,  as  these  disappear,  more  fibrous  tissue 
appears — the  "  vicious  circle "  is  established.  (2)  Another  cause  of  chronic 
interstitial  changes  in  muscle  is  atrophy.  When  a  muscle  atrophies  as  the  result  of 
a  central  or  peripheral  nerve  lesion,  fibrous  tissue  may  soon  appear  and  take  the 
place  of  the  muscle  fibres.  "  Tissue  degeneration,  if  not  repaired,  leads  to 
fibrosis";  degenerated  muscle  fibres  are  replaced  by  invading  and  proliferating 
connective  tissue.  Adami  has  spoken  of  this  form  of  fibrosis  as  "  a  replacement 
fibrosis."  It  seems,  therefore,  that  an  important  cause  of  progressive  chronic 
interstitial  myositis  is  the  degeneration  of  the.  muscle  fibres,  which  may  be  due 
(a)  to  an  acute  interstitial  inflammation,  or  (b)  to  myotrophic  or  neurotrophic 
lesions,  and  which  (c)  may  be  kept  up  by,  or  progress  with,  the  appearance  of  the 
fibrous  tissue. 

Similar  conditions  are  met  with  in  the  so-called  peripheral  neuritis  of 
diphtheria  or  lead  poisoning.  Sidney  Martin  and  others  have  shown  that  the 
earliest  stage  in  the  process  is  a  degeneration  of  the  nerves ;  this  is  followed  by  a 
proliferation  of  the  connective  tissue,  which  may  go  on  to  fibrosis.  In  the  spinal 
cord  the  degenerated  tracts  and  areas  are  replaced  by  fibrous  tissues.  In  these  cases 
there  is  no  sign  of  acute  inflammation,  no  dilatation  of  the  vessels,  no  appearance 
of  new  vessels,  no  leucocytic  infiltration,  but  merely  a  degeneration  which  excites 
the  connective  tissue  to  proliferation,  that  it  may  replace  the  lost  tissue.  This  is 
not  inflammation,  but  a  different  process  altogether. 

In  cirrhosis  of  the  liver  difficulties  arise,  since  the  intercellular,  lobular,  and 
biliary  types  differ  so  widely,  and  are  so  diverse  in  their  etiology  and  histology ; 
it  seems  impossible  to  explain  them  all  in  the  same  manner.  When,  however,  any 
form  of  cirrhosis  is  so  far  advanced  as  to  cause  so  marked  a  degeneration  of  the 
liver  cells  that  recovery  is  impossible,  then  the  degenerate  cells  may  act  as  a 
further  stimulus  for  progressive  fibrosis.  It  appears  that  the  primary  cause  of 
cirrhosis  is  always  a  degeneration  of  the  hepatic  cells  caused  by  some  toxine, 
such  .as  owes  its  origin  to  alcoholic  or  syphilitic  poisoning;  and  it  appears 
that,  when  the  process  of  cirrhosis  has  once  begun,  the  degenerated  cells  are 
replaced  by  fibrous  tissue,  and  that  the  degeneration  is  to  some  extent 
responsible  for  a  continuity  in  the  cirrhotic  process.  Obviously  the  connective 
tissue  must  be  in  a  position  to  respond  by  proliferation  before  a  fibrosis  can  result. 
If  its  activity  be  impaired,  either  because  the  whole  individual  is  atrophying, 
•or  because  it  is  itself  hopelessly  badly  nourished,  fibrosis  cannot  possibly  take 
place. 

Venous  engorgement  occasionally,  though  rarely,  leads  to  induration;  this 
induration  is  probably  due  to  the  engorgement,  which  causes  degeneration  of 
the  organic  cells ;  these  cells  are  then  replaced  by  proliferated  connective 
tissue.  Generally,  however,  the  tissues  are  too  badly  nourished  to  respond  by 
proliferation.     Where  general  debility  or  impairment  is  absent,  a  fatty  or  waxy 


38  GENERAL  PATHOLOGY  OF  DISEASE. 

metamorphosis  of  the  liver  may  be  accompanied  by  fibrosis,  as  in  true  fatty 
cirrhosis.  Cirrhosis  of  the  liver  is  always  due  to  proliferative  changes  in  the 
interstitial,  portal,  or  lobular  connective  tissue,  appearing  to  respond  to  cell 
degeneration,  which  promotes  the  progress  of  the  fibrosis. 

Ordinary  interstitial  nephritis  (red  atrophic  kidney)  may  be  produced  by 
primary  hyperplastic  changes  in  the  interstitial  connective  tissue ;  but  it  has  yet 
to  be  proved  that  it  is  a  primary  hyperplasia,  and  not  a  hyperplasia  called  into 
existence  by  degenerative  changes  in  the  renal  tissue.  The  chronic  interstitial 
changes  in  a  white  kidney  are  certainly  due  to  several  factors — (a)  the 
repeatedly  recurring  attacks  of  acute  or  subacute  inflammation ;  (b)  the  organic 
destruction  resulting  therefrom,  which  awakens  the  connective  tissue ;  and  (c)  the 
proliferative  energy  of  the  connective  tissue. 

The  various  forms  of  chronic  inflammation  may  be  reviewed  shortly  as  follows  : 
— (a)  Processes  which  begin  primarily  in  the  connective  tissue ;  fibrosis  appears 
and  progresses,  the  process  being  in  part  maintained  by  the  destruction  of  the 
organic  elements  (productive  fibrosis  of  Adami) ;  (b)  processes  which  begin  with 
an  atrophy  of  the  organic  elements,  the  latter  being  replaced  by  hyperplastic  con- 
nective tissue  (replacement  fibrosis,  Adami) ;  (c)  processes  which,  occurring  on 
free  surfaces,  involve  all  structures  concerned,  but  where  again  the  most  striking 
phenomenon  is  the  fibrous  hyperplasia,  included  under  productive  fibrosis,  by 
Adami. 

The  important  law  is  that  "  tissue  degeneration,  if  not  repaired,  leads 
to  fibrosis,"  provided  of  course  that  the  connective  tissue  is  capable  of 
further  growth — for  if  it  be  half  dead  itself,  it  cannot  possibly  assume 
fresh  vigour — and  provided  also  that  the  stimulus  for  proliferation  is. 
sufficient,  or,  adopting  Grawitz's  metaphor,  that  the  connective  tissue  has 
been  sufficiently  roused  and  awakened. 

"  Is  chronic  inflammation  an  inflammation  at  all  ? "  Inflammation 
is  recognised  by  its  appearances  and  phenomena,  and  inflammation  is 
not  synonymous  with  repair. 

In  microscopical  specimens  of  tissues  and  organs  undergoing  so-called  chronic 
inflammation,  the  appearances  of  inflammation  are  not  found,  but  appearances 
characteristic  rather  of  repair  by  fibrous  tissue.  True,  at  the  outskirts  of  a 
chronically  inflamed  area,  there  may  often  be  detected  a  few  dilated  vessels 
surrounded  by  clusters  of  round  cells,  but  the  bulk  of  the  specimen  shows 
nothing  that  could  be  called  inflammation.  Chronic  inflammation,  exhibiting  all 
the  changes  of  repair,  cannot  possibly  be  inflammation,  for  inflammation  ceases 
where  repair  begins,  and  chronic  inflammation  is  a  term  which  has  been  given  to> 
conditions  which  already  show  completed  repair,  or  which  show  excessive  repair. 
This  excessive  repair — the  hyperplasia  and  hyperplastic  tendency  of  newly  formed 
fibrous  tissue — is  an  important  element  in  some  forms  of  "chronic  inflammation."' 

An  acute  inflammation,  in  the  language  of  the  surgeon  or  physician,  is  fre- 
quently followed  by  a  chronic  inflammation.  What  does  this  signify  %  Merely 
this,  that  the  effects  of  the  acute  process  have  been  repaired  by  fibrous  tissue, 
developed  from  the  proliferating  connective  tissue ;  but  the  latter,  once  awakened 
to  increased  growth,  in  the  full  enjoyment  of  renewed  vigour,  continues  to  develop 
further  and  further  on  the  slightest  provocation.  An  acute  inflammation  is  often 
the  precursor  of  a  fibrosis,  but  surely  that  is  no  justification  for  calling  the 
resulting  fibrosis  a  chronic  inflammation. 

An  acute  nephritis  may  at  once  pass  into  gradual  and  progressive  induration 
(contracting  white  kidney)  on  account  of  such  excessive  repair.  But  in  most 
cases  where  a  fibrosis  has  followed  upon  an  acute  inflammation,  there  is  an  injured 
and  dying  tissue  left  behind,  which  acts  as  tbe  proliferative  stimulus  upon  a 
responsive  and  awakened  connective  tissue.  And,  what  is  still  more  important, 
in  most  cases    the   acute   inflammation   recurs    from    time  to   time,  and  rouses 


REGENERATION  AND  REPAIR.  39 

the  connective  tissue  to  continued  repair,  when  it  is  already  in  a  condition  of 
initial  fibrosis,  ready  to  proliferate,  so  that  every  fresh  acute  attack  only  makes 
matters  worse.  A  fibrosis  may  therefore  result  from  a  single  acute  inflammation, 
or  from  repeated  attacks  of  acute  inflammation,  but  on  this  account  it  is  not 
necessarily  to  be  looked  upon  as  an  inflammation. 

Instead  of  repeated  attacks  of  inflammation,  there  may  be  repeated  or  con- 
tinued irritation,  which  does  not  necessarily  produce,  or  may  stop  short  of 
producing,  an  inflammation.  In  most  cases,  no  doubt,  repeated  irritation 
does  lead  to  repeated  attacks  of  inflammation,  so  localised  and  so  slight 
that  they  are  not  recognised,  subjectively  or  objectively,  but  are  neverthe- 
less sufficient  to  awaken  the  connective  tissue  to  hyperplasia  and  fibrosis, 
and  also  to  cause  a  hyperplasia  of  the  epithelial  elements,  and  an  increased 
functional  activity.  But  even  then  the  inflammatory  attacks  themselves  do 
not  constitute  the  chronic  inflammation ;  they  simply  incite  to  hyperplasia  and 
hypertrophy. 

In  interstitial  processes,  especially  cirrhosis  of  the  liver  and  kidney,  there  is 
nothing  suggestive  of  the  presence  of  an  inflammation ;  but  there  is  fibrosis.  It 
may  be  said,  there  is  no  evidence  that  this  is  the  outcome  of  a  previous  inflamma- 
tion, the  processes  appearing  in  the  interstitial  tissue,  which  has  been  awakened 
either  by  irritant  substance,  or  by  degenerating  cells,  or  by  a  combination  of  the 
two  stimuli.  Possibly  here  and  there  an  acute  hepatitis  or  nephritis  may  have 
existed  to  begin  with,  but  then  it  merely  acted  as  the  initial  stimulus.  The 
essence  of  the  cirrhosis  is  the  progressive  fibrosis,  which  appeared  either 
independently  of  an  inflammation,  or  in  the  wake  of  an  inflammation  as  excessive, 
or  hyperplastic  repair. 

But  it  may  again  be  objected  that  necrobiosis  and  necrosis  in  myositis 
produce  inflammation,  and  that  therefore  tissue  degeneration  leads  to  in- 
flammation, and  that  the  term  chronic  inflammation  is  justified.  That  is 
only  true  to  a  certain  limited  extent,  where  large  necrotic  areas,  infarcts, 
hsemorhages,  and  such  like  lesions  are  concerned,  but  is  assuredly  not  true 
of  progressive  degeneration.  Even  infarcts  and  necrotic  areas  may  disappear 
in  a  scar,  without  any  actual  or  real  inflammation  ever  having  existed. 
The  necrosed  elements  must  first  be  removed.  This  may  be  done  by  a 
process  of  absorption  or  phagocytosis,  with  or  without  inflammation.  The 
dead  tissue  having  been  removed,  then  the  fibrous  tissue  fills  up  the  gaps. 
If  there  is  only  one  gap  to  fill  up,  a  cicatrix  is  formed — repair — but  that 
is  not  chronic  inflammation;  if,  however,  the  necrosis  or  degeneration  be 
both  extensive  and  progressive,  and  is  responded  to  by  equally  progressive 
reparative  proliferation,  then  fibrosis  ensues,  or,  in  ordinary  language,  chronic 
inflammation. 

Chronic  inflammation,  then,  may  be  regarded  as  a  hyperplastic  change  of  the 
connective  tissue,  occasionally  accompanied  by  hyperplasia  and  hypertrophy  of 
the  epithelial  and  glandular  elements,  produced  either  by  repeated  or  continued 
irritation  (extrinsic  or  intrinsic),  or  by  a  single  and  more  often  by  repeated  attacks 
of  inflammation ;  it  may  be  called  into  existence  by  progressive  tissue  degenera- 
tion, when  the  epithelial  and  glandular  elements,  of  course,  do  not  share  in  the 
hyperplastic  process.  An  inflammation  it  is  not,  because,  histologically,  it  is  a 
process  which  is  solely  concerned  with  tissue  elements  which  are  considered 
characteristic  of  repair ;  inflammation  is  not  even  a  constant  precursor.  It  would 
therefore  be  well  to  abolish  the  term  chronic  inflammation  from  morbid  anatomy 
and  histology,  if  not  from  clinical  medicine  and  surgery. 

Chronic  Inflammation  (so  called). 

I.  Chronic  Suppuration  (abscesses  or  ulcers). — Granulation  tissue  and  con- 
tinued irritation. 

II.  Chronic  Catarrh. — Proliferation  and  increased  functional  activity. 


4o  GENERAL  PATHOLOGY  OF  DISEASE. 

.,„    T  T  (  Eesult  of  degeneration. 

III.  Interstitial  Induration  I  °,.        ,  .    .,   ,. 

.  .    ,      .         j      ,        .  x  <  „         continued  irritation, 

(cn'riiosis  and  sclerosis)  .     ,  .  .  ■.  ,  ,    • 

v  '  {         „         cicatricial  hyperplasia. 

IV.  Superficial   Induration  ")-r>      ,,     -        ,.       ,  .    .,  , . 

,  ,  Kesult  oi  continued  irritation, 

(mucous     and  serous  >  .     ,  .  .  ,  ,  ,    . 

v        ,  x  (  ,,         cicatricial  hyperplasia, 

membranes)  J  Jr    x 

Eegeneratton  and  Eepaik. 

Tissues  which  are  used  up  during  ordinary  normal  wear  and  tear,  or 
which  have  been  destroyed  by  injury  or  other  pathological  processes,  must 
be  replaced  or  repaired  if  life  is  to  continue,  or  if  a  cure  is  to  be  effected. 
Eepair  may  be  either  direct  and  homologous  (regeneration),  or  indirect 
and  heterologous.  Thus  the  cuticular  cells,  the  epithelium  of  mucous 
surfaces,  are  constantly  reproduced,  new  cells  being  developed  to  take  the 
place  of  the  old  ones.  This  regeneration  is  purely  physiological,  and  is  a 
continuous  process.     Physiological  repair  is  always  homologous. 

Under  pathological  conditions  repair  is  more  rarely  homologous ;  as  a 
matter  of  fact,  it  is  more  commonly  indirect  or  heterologous.     Still,  it 
must  be  borne  in  mind  that  a  tissue  defect,  whether  due  to  injury,  degener- 
ation, or  any  other  cause,  may  be  made  good  by  regeneration.     Thus 
connective   tissue,  nerves,   and    vessels   may   be    regenerated;    but   the 
power   of  regeneration  varies  considerably  for  the  different  tissues,  and 
also  for  different  animals.     Thus,  while  certain  low  forms  of  animals  are 
capable  of  reproducing  whole  complex  organs,  man  and  most  warm-blooded 
mammalia  are  most  restricted  in  their  recuperative  powers.    Whole  organs 
are  never  reconstructed  in  man,  but  only  certain  tissue  elements.     Epi- 
thelium and  connective  tissues,  if  the  defect  be  limited,  may  be  regener- 
ated, the  regenerative  power  being   always   most  marked  in   the   least 
specialised  and  differentiated  cell  elements.    Thus  ganglion  cells  are  never 
reconstructed,  and  muscle  fibres  only  rarely  when  there  has  been  complete 
destruction;  but  when  only  a  portion  of  a  cell  has  been  destroyed,  the 
fragment  may  be  restored,  as  e.g.  the  process  of  a  ganglion  cell.     Again, 
tissues  which  have  become  mature  and  are  permanent  are  less  capable  of 
regeneration  than  tissues  which  are   more  or  less  temporary  and  con- 
structive.    Thus   the  periosteum   is   more  readily   re-formed  than  carti- 
lage.    The  regenerated  tissue  is  always  derived  from  homologous  tissue, 
i.e.  epithelium  is  derived  from  epithelium,  connective  tissue  from  con- 
nective tissue,  muscle  from  muscle,  etc. ;   connective  tissue  cannot  produce 
epithelium.     Eegeneration  obeys  rigorously  the  law  of  specificity,  owmxs 
cellula  e   celluld   (cpigenesis).     Where   homologous   repair   is    absent,  the 
defect  is  made  good  by  the  development  of  fibrous  or  cicatricial  tissue — 
the  common   form   of    repair.      Injured   or   degenerated    tissues,  if  not 
regenerated,  are  replaced  by  fibrous  tissue,  unless  the  organ  is  in  such  a 
condition  that  it  is  incapable  of  further  proliferation.     When  an  inflam- 
mation ends  in  resolution,  there  is  direct  repair  or  degeneration ;  when  it 
ends  in  induration,  indirect  repair  by  fibrosis ;  when  a  degeneration  such 
as  is  observed  in  peripheral  neuritis  passes  off,  and  the  affected  portions 
recover    themselves,  true    regeneration    takes    place;    while,  when  the 
degenerated  elements  disappear,  and  their  place  is  taken  by  fibrous  tissue, 
there  is  an  indirect  repair,  a  patching  up.     It  is  erroneous  to  suppose  that 
indirect  repair  is  always  accompanied  or  preceded  by  inflammation,  or  to 
define  any  attempt  at  repair,  whether  direct  or  indirect,  as  inflammation. 


METAPLASIA— HYPERTROPHY.  41 

Since  pathological  repair  implies  increased  proliferation,  it  will  be  readily 
understood  why  reparative  tissue  is  so  liable  to  hypertrophy;  the  pro- 
liferative stimulus  may  produce  a  more  or  less  lasting  effect  or  impression. 

Repair. 

I.  Direct  or  Homologous — 

r  Cuticle  \ 

(a)   Continuous  =  physiological     1  n?    j  °       /-"Wear  and  tear. 


(b)  Discontinuous  =  pathological 


I  Glands 
I  Periosteum 

Epithelium 

Connective  tissue 

Periosteum 

JSTerves 

Muscles 


Injury     or     de- 
generation. 


c  Mature  and  permanent  tissue, 

lopCfQ     f)T*P2-l^      OT      lnnifpn       OT* 

II.  Indirect  or  Heterologous  =  pathological^       ,   D  ,    ,  ,.       J    ,  .  ,  . 

r  °         j       degenerated  tissues,  highly 

{      specific  tissues. 

Eepair  must  not  be  confounded  with  recovery.  Homologous  or  direct 
repair  is  true  recovery ;  there  is  a  complete  restitutio  ad  integrum. 
Indirect  repair  is  something  entirely  different  from  recovery.  First  of 
all,  it  is  not  a  restitutio  ad  integrum  ;  secondly,  it  may  not  even  be  a  cure. 
Often,  no  doubt,  new-formed  tissue  acts  as  a  barrier  against  the  noxious 
agent,  and  encapsules  the  dead  matter  and  entraps  the  materies  morbi 
without  doing  harm  to  the  organ  and  its  function.  Frequently,  however, 
the  elements  of  the  organ  suffer,  its  function  becomes  impaired,  and  the 
attempt  at  cure  is  as  bad  as  the  disease.  Take,  for  instance,  a  fibroid  heart, 
the  fibrous  tissue  having  resulted,  let  it  be  assumed,  from  a  patching  up  of 
an  interstitial  myocarditis,  still,  the  newly  formed  tissue  weakens  the 
heart,  and  serious  symptoms,  nay  sudden  death,  may  result.  In  physio- 
logical repair  there  is  a  limit  beyond  which  matters  do  not  progress  in 
pathological  repair,  and  especially  when  it  is  heterologous,  the  patching  up 
may  be  carried  to  excess.     (See  "  Chronic  Inflammation,"  p.  35.) 

Metaplasia. 

Metaplasia  is  a  change  of  tissue  type — a  change  limited  and  following 
certain  laws ;  it  is  specific,  but  not  generic,  i.e.  a  connective  tissue  may 
Change  to  another  form  of  connective  tissue,  but  never  into  epithelium, 
and  an  epithelium  changes  to  another  form  of  epithelium,  but  never 
to  connective  tissue.  Metaplasia  is  naturally  commonest  in  the  pleomor- 
phic tissues ;  therefore  it  is  most  frequently  met  with  in  the  connective 
tissues.  Physiological  metaplasia  may  be  seen  in  the  development  and 
growth  of  bone,  in  the  formation  of  fat,  and  in  the  keratinisation  of 
epidermal  epithelium.  In  these  instances  the  metaplasia  is  a  continuous 
process ;  in  some  cases,  however,  it  is  discontinuous,  called  forth  by  certain 
stimuli.  Thus,  when  the  breasts  become  active,  there  is  a  metaplasia  from 
cubical  or  short  columnar  epithelium  to  a  secretory  or  glandular  type. 

Under  pathological  conditions  the  metaplasia  of  the  connective  tissue  may  be 
retrogressive  or  progressive.     Cartilage  may  change  into  myxomatous  tissue,  and 


42 


GENERAL  PATHOLOGY  OF  DLSEASE. 


fatty  tissue  into  a  fat-free  (Edematous  or  mucous  tissue.  These  are  instances  of  a 
retrogressive  metamorphosis.  On  the  other  hand,  cartilage  may  become  bone, 
mucous  tissue  cartilage,  or  fibrous  tissue  bone  ;  these  are  instances  of  a  progressive 
metamorphosis.  Tissue  which  has  resulted  from  repair  is  extremely  liable  to 
metaplasia,  and  so  is  the  tissue  of  certain  new  growths,  namely,  sarcomas.  The 
delicate  connective  tissue  which  appears  after  pleurisy  may  change  into  dense  and 
hard  fibrous  tissue,  and  the  latter  into  bone  or  cartilaginous  tissue. 

As  far  as  the  metaplasia  of  the  epithelium  is  concerned,  under  the  influence 
of  irritation,  (a)  columnar  epithelium  changes  into  squamous  epithelium,  and 
(b)  squamous  epithelium  may  become  horny.  But  squamous  epithelium  never 
becomes  columnar  or  ciliated.  Examples  of  a  metaplasia  of  columnar  epithelium 
may  be  looked  for  in  the  larynx,  nose,  or  uterus,  where,  as  the  result  of  so-called 
chronic  catarrh,  the  columnar  or  ciliated  cells  change  into  the  squamous  type,  and 
the  latter  may  even  become  keratinous.  This  metaplasia  of  the  epithelium  is 
most  important  in  connection  with  carcinoma.  A  cancer  developing  in  trans- 
formed epithelium  always  adheres  to  the  new  type  of  epithelium,  and  does  not 
revert  to  the  original  type. 


I.  Physiological — 


Metaplasia. 

II.  Pathological 


(a)  Continuous. — Ossification,  ker- 

atinisation,  fibrosis. 

(b)  Discontinuous.  —  Change       in 

breast  from  resting  to  active 
state. 


(a)  Connective      tissue.  —  Retro- 

gressive— cartilage  to  myx- 
omatous tissue. 
Progressive  —  cartilage        to 
bone. 

(b)  Epithelium. — Columnar    epi- 

thelium to  squamous — 
squamous  epithelium  to 
horny  epithelium. 


Hypeeteophy. 

Tissues  of  organs  and  limbs  may  increase  in  size  or  enlarge  under 
certain  conditions,  which  may  be  either  physiological  or  pathological. 
The  increase  in  size,  without  structural  changes,  constitutes  hyper- 
trophy. Under  physiological  conditions,  and  with  continued  exercise,  a 
muscle,  or  a  group  of  muscles,  may  enlarge ;  the  fibres  increase  both  in 
number  and  in  size.  Similarly,  the  heart  of  an  athlete  may  become  slightly 
enlarged.  It  must  be  remembered  that  the  body  is  so  constructed  that  in 
health  the  organs  are  not  worked  to  their  utmost,  and  that  they  are  capable, 
under  exertion,  of  doing  an  increased  or  even  an  enormous  amount  of  work ; 
if  these  demands  on  the  functional  activity  of  the  organs  is  kept  up,  they 
are  capable  of  adapting  themselves  to  the  new  requirements.  Physiological 
hypertrophy  is  therefore  a  process  of  adaptation. 

Under  pathological  conditions  hypertrophy  may  show  itself  as  the 
result  of  two  altogether  different  processes — (a)  it  may  be  due  to  adapta- 
tion, i.e.  compensatory  hypertrophy ;  or  (b)  it  may  be  due  to  an  abnormal 
proliferative  stimulus,  the  tissue  or  tissues  growing  and  expanding  without 
any  extra  demands  being  made  upon  them. 

Compensatory  hypertrophy  is  the  more  interesting  and  important 
form.  On  this  power,  which  the  body  and  portions  of  the  body  possess  to 
adapt  themselves  to  altered  conditions,  life,  in  health  and  disease,  greatly 
depends,  and  when  in  disease  the  limit  of  compensation  has  once  been 
reached,  death  soon  supervenes.     Compensation  or  adaptation  may  be  so 


PATHOLOGY  OF  B  AC  1"E  RIAL  INFECTION.  43 

complete  that  an  individual  seriously  maimed  may  be  able  to  live  a  long 
and  useful  life.  Compensation  is  not  exclusively  hypertrophic.  It  may 
be  merely  functional  or  vicarious,  one  organ  supplementing  another.  Com- 
pensatory hypertrophy  may  be — (1)  Supplementary,  upon  an  increased 
demand  for  work ;  (2)  vicarious,  affecting  a  whole  organ  after  loss  of  one 
of  a  pair  of  organs,  or  a  portion  of  an  organ  after  a  partial  loss  of  substance ; 
(3)  systemic,  where  a  lesion  is  counteracted  by  a  complete  readjustment 
of  several  or  even  numerous  organs  or  tissues.  Thus,  if  there  is  obstruc- 
tion to  the  outflow  of  urine,  the  bladder  wall  may  become  considerably 
thickened,  this  being  due  to  an  increase  of  its  muscular  substance ;  or, 
again,  if  there  is  an  obstruction  of  the  aortic  valve,  the  left  ventricle 
becomes  thickened,  more  force  being  required  to  propel  the  blood 
through  the  narrowed  opening.  So  long  as  the  hypertrophy  is 
adequate,  matters  may  progress  so  well  that  all  symptoms  of  disease 
are  practically  absent.  A  good  example  of  vicarious  hypertrophy  is 
the  enlargement  of  one  kidney  after  removal  or  total  obstruction 
of  the  other,  or  enlargement  of  a  part  of  a  kidney  after  atrophy  of 
the  remainder.  The  best  example  of  systemic  hypertrophy  is  also 
found  in  renal  diseases,  as  with  granular  kidney  when  the  left  ventricle 
of  the  heart  hypertrophies  and  the  tunica  media  of  the  arterioles  in- 
creases in  thickness. 

The  increase  in  size  is  due  chiefly  to  proliferation  of  the  tissue  constituents, 
without  change  of  structure,  hut  they  may  also  become  enlarged.  It  is  customary 
in  theory  to  distinguish  between  hypertrophy  and  hyperplasia.  In  either  case 
the  type  and  structure  of  the  tissue  remain  unaltered ;  in  hyperplasia  there  is  a 
numerical  increase  of  the  tissue  elements,  in  hypertrophy  an  increase  in  volume. 
Since,  however,  hypertrophy  is  always  accompanied  by  hyperplasia,  it  is  best  to 
call  any  increase  in  size  without  histological  change  hypertrophy,  even  though 
this  may  not  be  quite  accurate,  for  it  is  impossible  to  draw  a  hard  and  fast  line 
between  the  two  processes. 

Hypertrophy  or  overgrowth  may  he  either  primary  or  secondary.  Primary 
overgrowth  may  be  due  to  irritation,  or  possibly  to  long-continued  hyperemia  and. 
certain  nervous  changes  (pseudo-hypertrophic  paralysis),  but  its  cause  may  be 
altogether  obscure;  again,  it  may  involve  a  whole  organ,  i.e.  all  its  components,  or 
only  some  of  them.  A  whole  extremity  or  a  finger  or  toe  may  overgrow,  and  then 
all  the  components  are  hypertrophied ;  on  the  other  hand,  as  in  elephantiasis,  the 
skin  and  subcutaneous  tissue  only  may  increase.  Again,  a  breast  may  hypertrophy 
generally,  or  only  its  fat  or  glandular  substance  may  develop  abnormally.  When 
the  cause  of  the  overgrowth  is  obscure,  there  may  have  been  (1)  congenital  in- 
fluences (moles,  nasvi,  ichthyosis) ;  (2)  disease  (nails  and  teeth) ;  or  (3)  arrested 
involution  (uterus  and  breast),  but  often  even  then  no  explanation  can  be  found 
(lymphadenoma  and  goitres). 

In  secondary  overgrowth  a  new  tissue  is  first  produced,  either  as  the  result  of 
irritation,  inflammation,  or  atrophy,  metaplasia  or  heteroplasia,  and  this  new  tissue 
then  overgrows.  As  examples,  the  formation  of  keloids  and  exostoses,  developing 
in  common  with  muscular  and  tendinous  insertions,  may  be  mentioned ;  again, 
fibrous  tissue  may  appear  as  the  result  of  atrophy  (cirrhosis  of  the  liver,  senile 
changes  in  the  breast),  and  this  tissue  may  undergo  considerable  proliferation,  a 
so-called  hypertrophic  condition  being  produced. 

PATHOLOGY  OF  BACTERIAL  INFECTION. 

In  the  causation  of  diseases  and  morbid  lesions,  minute  vegetable 
organisms  play  an  important  part. 


44  GENERAL  PATHOLOGY  OF  DLSEASE. 


Chaeactees  of  Bacteeia. 

Classification. — The  pathologist,  awaiting  the  final  classification  of 
the  botanist,  temporarily  arranges  the  vegetable  bacterial  organisms  in 
morphological  groups,  and  he  uses  terms  which,  from  a  botanical  point 
of  view,  may  be  objected  to,  but  which  have  become  customary,  and 
will  probably  be  adhered  to  until  the  botanists  have  settled  their  dis-. 
putes.  Vegetable  micro-organisms  are  roughly  divided  into  (1)  fission 
fungi,  or  bacteria,  (2)  sprouting  or  budding  fungi,  and  (3)  mycelial 
fungi,  of  which  the  bacteria  are  the  lowest  and  simplest  forms,  and 
the  mycelial  fungi  the  highest  and  best  developed.  Most  disease- 
producing  organisms  belong  to  the  first  group,  a  few  only  to  the 
third.  The  budding  fungi  include  the  yeasts  which  are  responsible 
for  certain  processes  of  fermentation,  and  are  also  said  to  cause  tissue 
irritation. 

The  fission  fungi,  according  to  their  shapes,  are  again  divided  into  three 
main  groups : — 

1.   Cocci. — Globular,  subglobular,  oval,  ovoid,  or  reniform. 

(1)  In  chains —  ->  D  -,  .    7  , . 

v  '       i  \  cm.      i.  ■  [  Pyogenes  and  erysipelatis. 

(a)  Streptococci        .  .  .   i  D  • 

I  Pneumoniae. 


(2)  In  pairs — 

(b)  Diplococci 

(3)  In  tetrads — 

(c)  Tetracocci  . 

(4)  In  three  dimensions — 

(d)  Sarcinse 

(5)  In  irregular  clusters — 

(e)  Staphylococci 


( Pneumonice  (meningococcus). 
\  Gonorrhoeae,. 

Micrococcus  tetragenus. 

(  Pulmonalis. 
\  Ventriculi. 

(Pyogenes  aureus. 
<  gibus. 
\  citreus. 


The  streptococci  are  arranged  in  chains,  varying  considerably  in 
length,  the  diplococci  in  pairs,  the  tetracocci  in  fours,  the  sarcinse  in 
groups  of  fours,  and  the  staphylococci  in  irregular  masses.  This  classifi- 
cation, based  on  the  method  of  division,  though  useful,  is  extremely 
imperfect,  because  it  is  not  exclusive.  Thus  the  diplococcus  is  at  the 
same  time  the  simplest  form  of  streptococcus  or  of  staphylococcus.  The 
pneumococcus,  which  in  pneumonic  sputum  generally  occurs  in  encap- 
suled  pairs,  in  artificial  media  grows  as  a  streptococcus ;  the  Micrococcus 
tetragenus,  which  in  phthisical  cavities  is  found  in  fours,  surrounded  by 
a  capsule,  in  artificial  media  becomes  a  staphylococcus ;  so  also  do  most 
sarcinse. 

2.  Bacilli  include  all  rod-shaped  organisms.  They  are  generally 
long  or  short  straight  cylindrical  cells  with  rounded,  pointed,  or 
straight  ends,  but  some  of  them  are  clubbed  and  evince  a  ten- 
dency towards  branching.  The  latter,  strictly  speaking,  should  be 
taken  out  of  the  group  of  bacilli,  and  placed  amongst  the  mycelial 
fungi  in  a  class  by  themselves ;  they  are,  however,  as  a  rule  kept 
in  this  group.  The  following  bacilli  are  found  in  association  with 
disease  in  man: — 


INVOLUTION,  PLEOMORPHISM  AND   VARIABILITY.       45 


(1)  The  straight  bacilli —  (2)  The  clubbed  or  branched  bacilli — 

Bacillus  of  anthrax.  Bacillus  of  tuberculosis. 

„  glanders.  ,,        ,,  leprosy. 

„  typhoid  fever  (motile).  „        „  tetanus  (motile). 

coli  communis  (motile).  ,,        ,,  diphtheria, 

of       malignant       cedema  „        „  xerosis. 

(motile). 
„  blue  pus  (motile). 
„  tetanus  (motile). 
„  influenza. 
„  plague  (motile). 
„  Friedlander  (motile). 

Bacilli  may  be  motile  or  non-motile.  When  motile  they  possess  flagella., 
which  may  be  distributed  all  round  the  organisms,  as  is  the  case  with  the 
typhoid  and  tetanus  bacilli ;  or  they  may  be  fixed  at  one  or  both  poles, 
e.g.,  bacillus  of  blue  pus.  There  is  no  correlation  between  the  rapidity  of 
movement  and  the  number  of  flagella,  but  it  is  generally  held  by  botanists, 
who  divide  the  bacilli  according  to  their  flagellation  into  Monotricha  (a 
single  termal  in  flagellum),  Amphitricha  (a  single  flagellum  at  each  pole), 
Lophotricha  (a  bundle  of  flagella  at  one  pole),  and  Peritricha  (surrounded 
by  flagella),  that  the  arrangement  of  the  flagella  is  a  specific  character. 

Bacilli  always  divide  by  transverse  fission  into  (a)  paired  bacilli,  and 
(b)  filamentous  forms,  of  which  the  anthrax  bacillus  is  a  good  example. 
Many  bacilli  are  capable,  before  they  die,  of  producing  endogenous  spores, 
which  are  highly  refractive  bodies,  spherical  or  ellipsoid,  developing  in 
the  interior  of  the  cell  substances.  These  spores  are  highly  resistant  to 
the  action  of  physical  and  chemical  agents,  and  may  be  (1)  central 
(anthrax  bacillus),  or  terminal  (tetanus  bacillus),  or  indefinite.  The 
spore  placed  in  favourable  conditions  again  grows  into  a  bacillus.  The 
following  pathogenetic  bacilli  are  sporogenous : — (1)  Anthrax  (central 
sporulation).  (2)  Tetanus  bacilli  (terminal  sporulation).  (3)  Malignant 
cedema.  None  of  the  pathogenetic  cocci  or  spirilla  which  occur  in  man, 
sporulate. 

3.  Spirilla. — The  third  morphological  group  consists  of  the  vibrios — 
short,  small,  comma-shaped  organisms,  and  the  spirilla  of  longer,  tortuous, 
or  screw-like  threads.  The  vibrios  may  be  linked  in  such  a  way  as  to 
produce  a  jointed  spirillum  or  an  S-shaped  curve,  or  they  may  grow  into 
true  spirilla.  They  are  mostly  motile  and  flagellated.  The  most  important 
vibrio  or  spirillum,  from  the  pathogenetic  point  of  view,  is  that  of  Asiatic 
cholera ;  spirilla  and  vibrios,  however,  occur  commonly  enough  in  the 
intestinal  contents,  the  mouth,  tonsils,  and  nose,  and  are  often  found  in 
diarrhceic  stools. 


Involution,  Pleomorphism,  and  Variability. — Bacilli,  cocci,  and  spirilla, 
when  kept  in  or  on  artificial  media,  or  even  while  growing  in  the  animal 
organism,  frequently  show  changes  in  their  morphological  appearances.  In 
young  cultures  of  an  organism  the  different  individuals  resemble  each  other  very 
closely,  but  as  the  culture  becomes  older,  irregular  and  typical  forms  appear; 
this  is  degeneration  or  involution.  Such  degenerate  forms,  transplanted  on  good 
and  fresh  soil,  will  again  resemble  the  true  or  original  type.  Vibrios  when  grown 
on  agar-agar  or  in  other  media  frequently  become  coccoid ;  other  organisms  swell 
up  with  age  or  become  segmented.  In  other  cases,  e.g.  diphtheria  and  tubercle 
bacilli,  there  may  sometimes  be  noticed  in  young  and  perfectly  fresh  cultures 


46  GENERAL  PATHOLOGY  OF  DISEASE. 

curious  clubbed  or  branched  forms.  These  organisms  are  therefore  supposed  to  be 
closely  related  to  the  streptothrix  forms,  the  appearance  of  branched  forms  afford- 
ing an  example  of  a  progressive  metamorphosis.  Pleomorphic  organisms  even  in 
young  cultures  show  variety  of  shape,  the  pleomorphism  being  a  distinctive 
character  of  the  species. 

Pleomorphism  and  involution  must  not  be  confounded  with  variability.  On 
changing  the  external  conditions  and  soil  an  organism  will  vary  somewhat,  not 
only  in  its  morphological,  but  also  in  its  biological  characters ;  a  short  bacillus 
may  become  long,  and  a  pigment-producing  organism  may  lose  its  chromogenetic 
power.  Variability  is  possible  only  within  very  narrow  limits.  Morphologically 
an  organism  may  vary  in  shape,  but  the  limit  of  its  variability  is  fixed  by  its 
genus ;  thus  cocci  remain  cocci,  bacilli  remain  bacilli,  and  spirilla  remain  spirilla. 
Pleomorphic  organisms  retrogress  or  progress  to  a  higher  or  lower  class,  i.e.  an 
irregularly-shaped  bacillus  may  become  clubbed  or  branched.  We  still  speak  of 
diphtheria,  leprosy,  or  tubercle  bacilli,  but  it  is  questionable  whether  these  are 
bacilli  at  all,  and  do  not  rather  belong  to  a  special  genus.  Singling  out  the 
established  genera  amongst  the  vegetable  organism,  the  constancy  of  form  upheld 
by  Cohn  and  Koch  must  be  accepted ;  cocci,  bacilli,  and  spirilla  do  not  change 
one  into  the  other,  and  even  amongst  the  cocci  such  main  divisions  as  streptococci 
and  staphylococci  are  not  interchangeable. 

Variation  can  be  achieved  by  artificial  cultivation,  and  the  result  may  be 
(1)  a  temporary,  (2)  a  more  or  less  permanent,  and  (3)  an  absolutely  permanent 
variety.  If  a  variety  is  temporary,  on  restoring  the  old  condition,  reversion  to 
type  quickly  follows,  while,  as  the  endurance  of  the  variety  increases,  the  liability 
to  reversion  diminishes.  Variation  is  generally  due  either  to  degeneration  or  to 
adaptation  to  a  richer  or  better  soil :  in  the  former  case  variation  is  an  easy 
matter,  but  in  the  latter  variation  is  much  slower  and  can  often  be  produced  only 
by  a  process  of  selection,  that  is,  by  constantly  selecting  colonies  presenting  the 
features  which  it  is  wished  to  emphasise.  Variability  shows  itself  generally  in  the 
following  directions  : — (a)  Mode  of  growth,  namely,  changes  in  rapidity  of  develop- 
ment, in  the  amount  of  liquefaction,  in  the  size  of  the  colonies,  and  in  the  amount 
of  mucilaginous  material;  (b)  temperature — organisms  may  become  accustomed 
to  a  higher  or  lower  temperature  than  that  at  which  they  grow  best;  (c) 
oxygen  requirement — aerobic  organisms  may  be  trained  to  grow  under  anaerobic 
conditions,  and  conversely  anserobic  organisms  may  be  accustomed  to  aerobiosis ; 
(d)  resistance  to  antiseptics  ;  (e)  bio-chemistry — an  enzyme  may  be  lost  or  acquired 
by  change  of  medium,  a  pigment  lost  or  acquired,  and  a  toxine  increased,  diminished, 
or  lost  altogether;  (/)  sporulation — an  organism  may  be  so  modified  that  it 
loses  its  power  of  forming  spores.  It  is  important  to  note  that,  in  the  instances 
given,  variability  mostly  implies  loss  of  something,  rarely  the  acquisition  of  a 
higher  function.  Again,  variability  is  far  oftener  physiological  and  biochemical 
than  morphological.  It  is  quite  easy  to  alter  the  shape  of  a  bacillus  or  spirillum 
and  the  grouping  of  bacteria  by  a  change  of  medium,  but  then  this  change  is 
almost  always  temporary,  and  it  affects  only  a  larger  or  smaller  proportion  of  the 
organisms  growing  on  or  in  the  medium.  Taking  it  altogether,  there  is  as  yet  no 
reason  to  give  up  the  belief  in  the  constancy  of  form.  Physiological  and  bio- 
chemical properties  do  vary  considerably,  not  only  under  artificial  conditions,  but 
most  probably  also  in  nature,  and  it  is  more  than  possible  that  an  organism  may 
for  some  reason  or  another  suddenly  acquire  pathogenetic  properties. 

Eeqtjirements  of  Bacteeial  Life. 

Bacteria  require  oxygen,  nitrogen,  carbon,  hydrogen,  oxygen  phos- 
phorus, and  salts,  which  may  be  supplied  in  various  ways.  Nitrogen 
may  be  supplied  in  the  form  of  diffusible  albumins  and  peptones,  or  in 
the  form  of  non-albuminous  substances  containing  an  NH2  or  NH  group 


RE  Q  UIREMENTS  OF  BA  CTERIAL  LIFE.  4  7 

(leucin,  asparagin,  etc.),  or  even  in  the  form  of  nitrates.  It  is  important 
to  remember  that  pathogenetic  germs  may  be  cultivated  in  non-albuminous 
solutions,  because  this  proves  that  organisms  work  up  their  poisons  in 
their  own  substance,  and  not  by  splitting  up  the  solution  in  which  they 
grow.  Carbon  may  be  supplied  either  with  the  diffusible  albumins  and 
peptones,  or  in  the  form  of  sugar  or  other  carbohydrates,  glycerin  or  fat ; 
it  is  obtained  from  the  above  substances.  Phosphorus  may  be  given  as 
phosphates,  but  is  generally  present  in  the  ordinary  albuminous  substances 
used. 

Tlie  oxygen  requirement. — The  pathogenetic  organisms  may  be  divided 
into  three  groups,  according  to  their  behaviour  towards  oxygen.  Some 
organisms,  e.g.  bacillus  of  tetanus  or  bacillus  of  malignant  oedema,  grow 
in  an  atmosphere  devoid  of  oxygen,  and,  so  far  as  the  best  evidence  goes, 
cannot  grow  in  the  presence  of  free  oxygen,  they  are  therefore  obligatory 
ancerobes.  Others  require  the  presence  of  free  oxygen,  and  are  obligatory 
aerobes;  but  the  majority  of  bacteria  are  facultative  anaerobes,  i.e.  they 
are  capable  of  growing  in  an  atmosphere  devoid  of  oxygen,  and  also 
in  the  presence  of  free  oxygen,  some  growing  better  without — others 
better  with  it.  Most  pathogenetic  organisms  which  in  the  laboratory 
grow  as  aerobes,  in  the  body  produce  their  lesions  and  diseases  as 
anaerobes,  for  in  the  tissues  there  is  no  free  oxygen.  Pasteur  thought 
that  bacteria  and  yeasts  developed  their  fermentative  and  chemical 
activity  best  in  the  absence  of  oxygen.  This  does  not  appear  to  be 
an  absolute  law,  although  it  cannot  be  denied  that  the  absence  of 
oxygen  often  provokes  a  more  intense  fermentation.  Further,  many  of 
the  organisms  which  in  the  tissues  are  anaerobic  can,  outside  the  body,  be 
grown  without  oxygen  only  with  difficulty  or  not  at  all.  This  shows  how 
imperfectly  the  test  tube  supplies  the  conditions  existing  in  the  living 
body.  (2)  The  range  of  temperature  at  which  bacterial  life  is  possible 
varies  considerably.  There  are  organisms  which  grow  at  a  low  tem- 
perature, under  15°  C,  others  which  can  only  grow  at  a  temperature  of 
the  human  body  and  up  to  40-42o-5  C,  and  others  again  which  grow  at 
any  temperature  between  10°  C.  and  42° -5  C.  The  most  extraordinary  are 
the  thermophilic  organisms,  found  in  faeces,  which  only  develop  at  tem- 
peratures above  45°  and  up  to  60°  C. ;  they  appear,  however,  to  be  of  no 
pathological  importance.  All  pathogenetic  organisms  are  capable  of  growth 
at  blood  temperature  ;  some  readily  perish  if  kept  below  this  temperature ; 
others,  however,  persist  either  in  a  vegetative  form,  or  as  spores,  or  in  a 
dormant  and  latent  condition,  often  retaining  their  full  virulence.  Thus 
the  staphylococci  of  suppuration  thrive  well  at  low  temperatures,  as  does  the 
typhoid  bacillus ;  the  bacilli  of  anthrax  and  tetanus  form  spores  ;  while  the 
tubercle  bacillus  and  streptococci  retain  their  vitality,  the  latter  even 
when  kept  in  an  ice  chest.  Again,  higher  temperatures  may  be  borne  by 
many  organisms,  either  by  virtue  of  their  own  natural  resistance  or  by 
their  power  of  sporulation.  Many  pathogenetic  organisms,  then,  possess 
a  strong  vitality,  the  far-reaching  importance  of  which  fact  will  be 
evident.  (3)  Light,  generally  speaking,  is  harmful  to  most  pathogenetic 
organisms,  either  destroying  them  outright,  or  at  least  attenuating  them, 
or  modifying  them.  Direct  sunlight  is  infinitely  more  potent  than  diffuse 
light,  and  the  actinic  more  powerful  that  the  heat  rays.  Apparently  con- 
tact with  free  air  is  necessary  for  the  perfecting  of  this  action,  and  it  is 
believed  that  the  sunlight  in  the  presence  of  free  air  produces  either 
ozone  or  H202,  and  that  the  bacteria  are  destroyed  by  these  substances. 


48  GENERAL  PA  THOL  OGY  OE  DISEA SE. 

(4)  High  altitudes  and  great  atmospheric  pressure  are  inimical  to  the 
development  of  pathogenetic  germs. 

It  is  important  in  all  cases  to  study  the  effect  of  surroundings  and 
physical  conditions  on  disease-producing  organisms,  because  it  is  evident 
that  a  resistant  germ  is  a  much  more  difficult  foe  to  grapple  with  than  one 
which  is  very  sensitive. 

Vital  Manifestations  of  Bactekia. 

It  is  evident  that  chemical  changes  take  place  during  bacterial 
growths,  for  nutrition  depends  on  them ;  energy  is  developed  as  a  result 
of  such  growth.  Nutrition  has  two  objects  to  fulfil — (a)  to  supply  the 
bacteria  with  food  material  for  their  own  development  and  proliferation ; 
(b)  to  supply  the  substances  required  for  the  development  of  energy.  For 
mere  vegetation  plastic  nutriment  alone  is  necessary,  i.e.  simple  substances  ; 
but  for  the  display  of  energy,  additional  food  material,  and  additional 
chemical  substances  are  required. 

A  change  of  medium  or  surroundings  may  alter  the  activity  of  an  organism  ; 
virulent  bacteria  after  their  removal  from  the  body  may  become  attenuated,  and 
organisms  which  generally  merely  vegetate  on  the  mucous  or  other  surface  of  the 
body  may  under  certain  conditions  acquire  marked  virulence.  A  virulent  strepto- 
coccus can  be  kept  for  a  long  time  in  vegetative  form  on  gelatin  in  a  refrigerator, 
so  that  when  again  injected  into  the  animal  body  it  once  more  gives  unequivocal 
evidence  of  its  virulence.  The  pneumococcus  on  a  mucous  membrane,  so  long  as 
it  is  merely  supplied  with  plastic  food  material,  simply  vegetates  in  a  harmless 
way,  but  a  change  of  conditions  which  implies  a  change  of  medium  will  cause  it 
to  display  an  unexpectedly  virulent  activity.  Nutrition,  whether  for  the  purpose 
of  vegetative  growth  or  for  the  purpose  of  developing  energy,  is  a  process  of 
assimilation,  i.e.  of  synthesis,  but  this  must  always  be  accompanied  by  an  output 
of  certain  substances.  The  latter  includes  (a)  waste  products,  and  (I)  the  pro- 
ducts of  intracellular  chemical  activity,  i.e.  secretions,  which  are  often  capable  of 
calling  forth  fresh  chemical  processes. 

Bacterial  products. — By  these  are  understood,  generally,  the  sum 
total  of  substances  which  are  found  in  a  medium  in  which  the  bacteria  have 
grown  for  some  time.  Hence  they  evidently  include  both  the  excreta  and 
the  secretions  of  these  organisms.  The  medium  may  be  altered  in  many 
ways — (1)  organisms,  growing  in  broth,  use  up  certain  substances,  and 
hence  alter  the  chemical  nature  of  the  broth,  by  removing  them ;  (2)  they 
may  destroy  others  by  splitting  them  up ;  (3)  the  excreta  may  form  new 
compounds  with  substances  found  in  the  broth;  (-4)  the  secretions, 
especially  if  of  the  nature  of  enzymes,  may  by  their  action  lead  to  the 
formation  of  a  new  series  of  molecular  changes,  which  will  greatly  alter 
the  medium ;  and  (5)  the  organisms  may  act  as  ferments,  and  still  further 
alter  the  medium.  Hence  the  chemical  activity  of  an  organism  is  extremely 
diverse,  and  depends  on  a  number  of  often  highly  complex  processes,  our 
knowledge  of  which  must  necessarily  be  at  present  both  limited  and  crude. 

Amongst  the  numerous  so-called  bacterial  products  may  be  found  the  following 
substances: — (1)  Gases,  (2)  water,  (3)  nitrates  and  nitrites,  (4)  sulphur,  (5)  vola- 
tile bodies,  (6)  oxy-acids,  (7)  sulpho-acids,  (8)  amido-compounds,  (9)  aromatic 
bodies,  (10)  indol,  (11)  pigments,  (12)  carbohydrates,  (13)  peptones  and  albumoses, 
(14)  ptomaines  and  so-called  alkaloidal  substances,  (15)  toxines  and  toxalbumins, 
(16)  enzymes,  (17)  the  extracts  of  the  dead  bodies  of  the  bacteria,  and  (18)  other 


FERMENTA  TION— ENZYMES.  49 

products  of  fermentation.  All  these  substances  are  not  found  at  once  in  the 
chemical  products  of  one  and  the  same  organism,  hut  this  extraordinary  multitude 
and  diversity  of  the  bacterial  products  must  be  borne  in  mind,  because  they  show 
what  the  organisms  may  do,  and  how  diverse,  in  disease,  the  phenomena  due  to 
bacterial  intoxication  may  be.  A  few  chemical  processes,  which  have  some  bear- 
ing on  health  and  disease,  may  be  instanced: — (a)  Organisms  may  be  strong  reduc- 
ing agents,  and  may  thus  assist  complex  physiological  processes.  Thus  putrefac 
tion  is  essentially  a  reducing  process,  and  whether  it  is  absolutely  necessary  or 
not,  putrefaction  certainly  assists  digestion  and  absorption,  and  prevents  intoxica- 
tion from  the  intestinal  tract,  (b)  Nitrates  are  reduced  to  nitrites,  an  indispens- 
able preliminary  process  in  nitrification,  which,  if  not  absolutely  necessary  for 
some  forms  and  phases  of  vegetable  life,  yet  is  of  great  use  to  them.  By  nitrifi- 
cation ammonia  is  changed  into  nitrates ;  this  process  is  a  double  one — (a)  one 
group  of  organisms  changes  ammonia  to  nitrites,  and  (b)  a  second  group  changes 
the  nitrites  into  nitrates.  The  nitrifying  organisms  are  frequently  associated  with 
the  leguminous  plants,  which  use  them  for  their  own  development.  They  can, 
however,  do  without  them  when  ammonia  or  nitrates  are  present  in  sufficient 
quantity.  This  shows  that,  although  not  essential  to  life,  these  organisms,  under 
ordinary  conditions,  are  of  the  greatest  use.  It  may  be  that  bacteria  are  not 
essential  for  subsistence  and  growth,  but  by  a  process  of  adaptation  the  animal 
organism  may,  for  the  purpose  of  nutrition,  have  learnt  to  avail  itself  of  the 
assistance  of  bacteria.  Putrefaction,  which  normally  takes  place  in  the  intes- 
tinal tract,  and  may  reasonably  be  regarded  if  not  as  an  essential  as  a  useful 
process,  as  aiding  in  the  splitting  up  of  complex  bodies,  and  in  the  destruction  of 
poisonous  bodies,  is  of  course  due  to  bacterial  action,  and  is  a  complex  chemical 
process  resulting  from  bacterial  fermentation,  i.e.  not  a  simple  fermentation,  but  a 
compound  fermentation.  The  following  steps  may  be  distinguished : — (a)  The 
albuminous  substances  are  changed  by  some  bacteria  into  peptones  and  albumoses, 
by  what  appears  to  be  a  process  of  hydrolysis ;  (6)  these  peptones  and  albumoses 
are  then  split  and  changed  into  amido-acids  and  amides,  nitrogenous  aromatic 
bodies  and  sulpho-acids  (such  as  taurin)  also  making  their  appearance ;  (c)  the 
amido  compounds  are  then  decomposed  into  ammonia  and  fatty  acids ;  (d)  the 
ammonia  is  then  altered  by  bacteria,  as  described  under  nitrification,  and  the  fatty 
acids  are  split  into  CO.,,  H2,  and  CH4.  The  products  of  putrefaction  vary  with 
the  bacterial  flora,  and  also  with  the  presence  or  absence  of  oxygen.  If  oxygen  is 
absent,  true  putrefaction  takes  place ;  if  it  is  present,  decomposition  characterised 
by  an  absence  of  the  bad  and  offensive  odour,  and  frequently  accompanied  by 
reduction  of  the  nitrates  (dentrification),  by  which  JS"2  may  be  split  off. 

Fermentation  may  be  brought  about  by  (a)  non-organised  substances, 
the  products  of  secreta  (excreta)  of  bacteria,  the  enzymes,  or  (b)  by  the 
living  bacteria  themselves,  which  then  act  as  true  ferments.  The  enzymes 
may  be  isolated  from  the  living  bacteria,  of  which  they  are  the  products, 
and  are  characterised  by  the  following  points : — (a)  They  are  capable  of 
splitting  up  H2Oo ;  (b)  they  are  extremely  sensitive  to  external  influences — 
in  the.  moist  condition  they  are  readily  destroyed  by  heat,  in  the  dry 
state  they  resist  100°-160°  C. ;  (c)  certain  salts,  such  as  aluminates  and 
phosphates,  and  nitrogenous  substances — asparagin — assist  the  enzymes  in 
carrying  on  their  fermentative  activity;  (d)  they  are  more  resistant  to 
external  influences  while  active,  especially  in  the  presence  of  neutral  salts 
(sulphates) ;  (e)  they  set  up  hydrolytic  action,  during  which  one  or  more 
molecules  of  H20  are  taken  up,  and  a  molecule  of  the  fermenting  substance 
is  split  into  two  or  more  molecules  of  a  simpler  substance ;  (/)  they  act  on 
certain  special  substances  only,  and  show  a  selective  power  as  striking  as 
that  shown  by  the  living  micro-organisms ;  (g)  their  quantitative  action  is 
considerable,  but  by  no  means  unlimited,  the  enzyme  apparently  forming 
vol.  1. — A 


50  GENERAL  PATHOLOGY  OF  DLSEASE. 

an  unstable  compound  with  the  products  of  decomposition,  which  is  easily 
split  up,  and  the  enzyme  again  set  free  on  the  addition  of  fresh  material.  The 
enzymes  are  closely  allied  to  the  toxines  of  disease-producing  organisms,  and 
for  that  reason  they  deserve  special  consideration.  The  following  enzymes 
have  been  isolated  from  living  bacteria : — 

Amylase,  which  converts  starch  into  sugar  (diastase),  found  in  anthrax  bacilli, 
and  the  vibrios  of  cholera  and  of  Finkler-Prior. 

Invertase,  which  converts  cane  sugar  into  dextrose  (found  especially  in  yeast 
cells). 

Glucoside  enzymes,  splitting  glucosides  into  dextrose,  and  a  body  of  entirely 
different  composition. 

Cellulose  enzymes,  capable  of  dissolving  cellulose. 

Peptonising  enzymes,  converting  albuminous  substances  into  peptones  and 
albumoses  (found  in  all  organisms  which  liquefy  gelatin). 

Milk  curdling  enzymes,  found  notably  in  the  Bacterium  coli. 

Urea  enzyme,  found  in  the  Micrococcus  urece,  which  converts  urea  into 
ammonium  carbonate,  hippuric  acid  into  glycocol  and  benzoic  acid. 

Fat-splitting  enzymes,  splitting  neutral  fats  into  glycerine  and  fatty 
acids. 

All  these  enzymes  may  be  obtained  from  the  bodies  of  micro-organ- 
isms. Thus,  on  destroying  yeast-cells  in  a  watery  suspension  by  shaking 
them  up  with  chloroform,  invertase  remains  in  suspension.  The  enzymes 
may  display  their  activity  either  outside  the  cell  (extracellular),  or  in  the 
cell  (intracellular)  enzymes.  An  extracellular  enzyme  is  secreted  or  ex- 
creted by  the  cell,  and  then  works  upon  the  material  in  which  the  cell  is 
suspended,  while  an  intracellular  enzyme  acts  upon  the  material  taken 
into  the  cell  substance,  splitting  it  up  by  a  process  of  hydrolysis.  The 
opinion  is  gaining  ground  that  under  normal  conditions  the  enzyme  action 
takes  place  in  the  interior  of  the  living  cell.  Thus  living  and  normal  yeast 
cells  do  not  give  off  invertase,  but  the  inversion  takes  place  in  the  cell 
body ;  only  when  the  cell  dies  is  the  inversion  given  off,  just  as  in  fermenta- 
tion, where  the  process  is  assumed  to  be  a  vital  one,  i.e.  an  intracellular 
one,  although  in  other  respects  it  closely  resembles  zymotic  action.  Thus 
a  few  organisms  will  produce  an  effect  out  of  all  proportion  to  the  number 
of  living  organisms  used;  in  both  cases  a  definite  medium  of  a  certain 
chemical  composition  is  required.  Ferment  action  and  enzyme  action  are 
so  closely  allied  that  it  may  be  doubted  whether  they  are  really  two  distinct 
processes.  Hitherto,  for  instance,  it  has  been  believed  that  the  yeast  cell, 
by  some  vital  process,  changes  glucose  into  alcohol.  Recently,  however,  an 
extract  has  been  prepared  of  yeast  cells,  which,  in  the  absence  of  all  living 
cells,  is  capable  of  fermenting  sugar  solution.  The  great  difficulty  has 
been  to  separate  this  substance  from  the  cell.  We  must  therefore  believe 
that  the  yeast  cell  takes  up  sugar,  and,  by  means  of  an  enzyme-like  body  in 
its  substance,  splits  it  up  into  alcohol  and  other  substances,  just  as  inver- 
tase in  the  cell  substance  inverts  cane  sugar.  The  yeast  cells  therefore 
build  up  two  enzymes — {a)  invertase,  and  (&)  alcoholic  enzymes,  of  which 
the  former  is  easily  given  off,  while  the  latter  is  obtained  with  much 
greater  difficulty.  Sugars  are  taken  up  by  the  living  cells,  and  cane  sugar 
inverted  by  the  appropriate  enzyme  in  the  substance  of  the  living  cell,  and 
either  given  off  again  as  glucose  or  at  once  changed  into  alcohol  by  the 
other  intracellular  enzyme.  It  is  legitimate,  in  the  present  state  of  our 
knowledge,  to  assume  that  the  processes  which  are  brought  about  by  patho- 
genetic bacteria  are  comparable  to  those  of  the  yeast  cell. 


PTOMAINES,   TOXALBUMINS,  TOXINES.  51 

The  yeast  cell  (a)  will  only  develop  its  fermentative  power  on  suitable 
media :  on  others  it  will  merely  vegetate  without  giving  evidence  of  its 
energy,  (b)  In  a  suitable  medium  its  energy  depends  upon  and  varies  with 
such  conditions  as  absence  of  oxygen,  concentration,  accumulation  of  the 
products  of  fermentation  and  of  waste,  (c)  Although  fermentation  varies 
with  the  rapidity  of  proliferation  on  the  part  of  the  yeast  cell,  alcoholic 
fermentation  will  still  take  place,  when  the  cells  have  ceased  to  multiply; 
it  appears  that  first  the  cell  reaches  its  maximal  vegetative  energy,  and 
then  unfolds  its  maximal  fermentative  energy,  (d)  The  yeast  possesses  two 
fermenting  substances,  of  which  one  is  of  nutritive  or  plastic  importance, 
namely,  the  invertase,  which  the  cell  will  only  use  when  it  is  placed  in  an 
unsuitable  sugar  solution;  whilst  the  other  is  of  specific  importance,  is 
firmly  fixed  in  the  cell  substance,  and  is  only  separated  with  difficulty. 
This  latter  substance  acts  on  certain  chemical  bodies  absorbed  into  the 
cell,  and  then  the  latter  give  off  an  elaborated  product,  which  may  be 
regarded  as  the  specific  toxine  of  the  yeast  cell,  namely,  the  alcohol.  By 
way  of  an  example,  take  the  diphtheria  bacillus.  The  latter  may  vegetate 
on  the  tonsil  as  a  saprophyte,  without  producing  any  lesions ;  under  certain 
conditions  it  becomes  virulent,  multiplies  rapidly,  and  then  displays  its 
energy.  It  forms,  if  necessary,  albumoses  by  an  enzyme,  and  at  the  same 
time  takes  up  substances  from  the  nutrient  material,  and  elaborates  these 
into  the  diphtheria  toxine,  which  is  the  specific  product ;  the  albumoses 
are  of  secondary  importance,  and  will  not  appear,  for  instance,  when  the 
bacillus  is  grown  in  a  solution  of  asparagin.  Disease-producing  organisms 
elaborate  poisonous  substances,  which  call  forth  certain  symptoms,  of 
which  some  are  specific,  and  belong  exclusively  to  a  particular  species, 
while  others  are  general  and  shared  by  many  organisms.  The  poisonous 
substance  obtained  from  a  tetanus  culture,  for  instance,  which,  when 
injected  into  an  animal,  produces  tetanus,  is  the  specific  poison;  other 
poisonous  substances,  which  merely  produce  fever  and  other  general 
symptoms,  are  not  specific,  and  may  be  found  in  many  other  organisms. 
It  is  a  matter  of  the  greatest  importance  to  keep  in  mind  this  twofold 
nature  of  the  poisonous  substance  of  disease-producing  organisms. 

Ptomaines. — The  ptomaines  are  nitrogenous  bases,  which  bear  some 
resemblance  to  the  vegetable  alkaloids ;  they  are  frequently  described 
as  cadaveric  or  animal  alkaloids.  Brieger  divided  them  into  two  groups — 
the  toxic  and  the  atoxic  ptomaines.  He  succeeded  in  obtaining  from  putre- 
fying material  and  from  pure  cultures  of  bacteria  on  meat,  both  forms  of 
ptomaines.  Most  of  the  atoxic  ptomaines  are  amines — cholin,  neuridin 
(putrefying  meat),  gadinin  (putrefying  fish),  putrescin,  and  cadaverin,  but 
the  toxic  ptomaines  are  also  closely  allied  to  the  amines ;  the  best  known 
of  these  are  neurin,  muscarin,  mytilotoxin,  and  tyrotoxicon.  Brieger 
obtained  poisonous  ptomaines  from  cultures  of  the  B.  typhosus,  the  cholera 
vibrio,  and  the  bacillus  of  tetanus,  and  at  one  time  believed  that  the  specific 
toxiues  were  ptomaines;  but  ptomaines  have  not  been  found  in  all  patho- 
genetic cultures,  whilst  quantitatively  they  are  present  in  such  a  small 
amount  in  others,  that  it  is  impossible  to  regard  them  as  being  the  specific 
toxines.  During  putrefaction  ptomaines  appear,  and  since  this  takes  place 
both  outside  and  inside  the  alimentary  tract,  poisoning  may  be  produced 
either  through  ptomaines  ingested  with  food,  or  through  ptomaines 
developed  in  the  alimentary  tract  after  the  ingestion  of  food.  The  term 
"ptomaine  poisoning"  is  often  employed  without  there  being  sufficient 
evidence  to  justify  its  use,  and  it  must  also  be  remembered  that  the  process 


5 2  GENERAL  PA THOL OGY  OF  DISEA SE. 

of  analysis  offers  numerous  sources  of  error  arising  from  the  extremely 
complicated  nature  of  the  chemical  manipulation. 

When  Hankin  and  Sidney  Martin  discovered  toxic  albumoses  in  anthrax 
cultures,  the  specific  poisons  were  thought  to  be  albuminous  substances  which 
were  called  toxalbumins.  In  diphtheria  cultures  a  poisonous  body  resembling 
serum  albumin  was  found,  and  separated  by  Brieger  and  Frankel ;  in  other 
cultures,  globulindike  substances ;  in  others,  again,  toxic  peptones,  so  that  dis- 
tinctions were  made  between  toxalbumoses,  toxoglobulin,  and  toxopeptones.  All 
these  substances  were  included  in  the  term  'Hoxalburnins."  The  latter  un- 
doubtedly contain  specific  toxines,  since,  on  injection,  they  reproduce  the  specific 
lesions  or  symptoms  of  the  infection ;  but  the  question  which  was  soon  raised 
was,  whether  these  toxalbumins  were  pure  substances  or  a  mixture  of  albuminous 
bodies  with  the  toxine.  Thus  Roux  and  Yersin  separated  from  diphtheria  cultures 
a  specific  toxine  which  appeared  to  be  an  enzyme.  Previously  chemists  had 
pointed  out  that  it  was  necessary  to  work  with  culture  fluids  containing  known 
substances,  and  to  free  the  bacterial  products  as  thoroughly  as  possible  from 
albuminous  substances.  Recent  work  has  shown  that  when  an  attempt  is  made 
to  precipitate  the  toxines  from  albuminous  solutions,  the  toxines  are  carried  down 
mechanically  with  the  globulins,  albuminoses,  or  peptones ;  and  therefore,  accord- 
ing to  the  constitution  of  the  culture  medium,  the  same  bacterial  toxine  at  one 
time  may  appear  to  be  a  globulin,  at  another  time  an  albumose,  and  that,  as  a 
matter  of  fact,  the  worker  has  usually,  if  not  always,  to  deal  with  mixtures  of 
toxine  and  albumose  or  toxine  and  globulin.  When  diphtheria  bacilli  are  grown 
in  an  albuminous  solution,  there  appears,  as  shown  by  Sidney  Martin,  a 
mixture  of  albumoses,  but,  as  shown  by  Uschinsky,  in  a  medium  free  from 
albumin,  a  toxine  free  from  albuminous  matter  is  obtained,  whilst  Brieger 
and  Cohn  have  succeeded  in  purifying  the  toxines  of  tetanus  and  diphtheria 
from  all  albuminous  admixture,  and  Dr.  Martin  has  extracted  from  the  tissues 
of  animals  dead  of  tetanus,  a  toxine  which  is  certainly  not  an  albuminous 
substance. 

These  purified  toxines  undoubtedly  resemble  the  enzymes  in  some  respects,  but 
they  cannot  be  grouped  with  the  enzymes,  because  their  activity  is  essentially 
diffused  and  their  action  narrowly  limited  by  the  dose  employed,  while  zymotic 
action  is  out  of  all  proportion  to  the  dose  of  enzyme  used.  It  may  be  assumed, 
however,  that  the  specific  toxines  are  products  of  the  bacterial  cells,  which  take  up 
certain  substances,  work  them  up  into  toxines,  which  are  then  excreted  or  secreted, 
and  that  the  albumoses,  globulins,  etc.,  are  merely  secondary  products  due  to  the 
action  of  accessory  enzymes. 

Amongst  the  non-specific  bacterial  products  the  most  important  are  the  proteins 
of  Biichner,  apparently  identical  with  Klein's  intracellular  poison,  while  the 
latter's  extracellular  poison  is  practically  the  same  as  the  specific  toxine.  The 
proteins  are  the  protoplasmic  substances  of  the  bacterial  cells,  and  may  be  obtained 
by  taking  masses  of  bacterial  cultures  grown  preferably  on  solid  media,  such  as 
potatoes,  agar-agar,  and  gelatin,  destroying  them  by  heat,  and  extracting  them  by 
alkalies  or  other  chemicals.  The  nature  of  these  proteins  is  not  as  yet  clearly 
understood  ;  some  observers  believe  that  the  proteins  of  the  different  bacteria  are 
identical  in  nature.  This,  however,  is  certainly  erroneous,  because  the  immunity 
produced  by  injection  of  the  so-called  proteins  is  strikingly  specific,  and  it  is 
probable  that  what  are  usually  called  proteins  are  mixtures  of  different  bodies,  t 
amongst  which  even  the  specific  toxines  in  small  quantities  may  occur.  It  seems, 
however,  that  there  are  also  other  substances,  found  in  many  bacteria,  which  are 
non-specific  in  their  action,  and  are  capable  of  producing  febrile  symptoms,  leuco- 
cytosis,  inflammation,  and  other  general  changes.  It  must  be  clearly  borne  in 
mind  that  the  pathogenetic  bacteria,  besides  secreting  toxines,  are  themselves 
poisonous,  and  that  this  coexistence  of  specific  and  non-specific  poisons  explains 
the  difference  and  diversity  of  symptoms  in  infective  lesions,  of  which  some  are 


PARASITIC  AND  SAPROPHYTIC  ORGANISMS.  53 

specific  and  others  general  and  non-specific.  The  chemical  changes  that  go  on  in 
a  test  tube  are  extremely  complex,  and  those  in  the  body  must  be  equally,  if  not 
more  so. 

Infection. 

There  are  a  number  of  infectious  diseases  or  lesions  which  never 
occur  without  the  presence  of  micro-organisms  in  the  tissues  or  in  the 
body  cavities.  An  infection  must  be  defined  as  a  morbid  change  pro- 
duced in  the  body  by  bacteria,  and  a  disease  or  a  lesion  is  infective  or 
infectious  if  it  be  thus  produced.  An  organism  capable  of  manifesting 
its  presence  by  infection  is  a  pathogenetic  organism.  Bacteria  may  be 
roughly,  but  not  absolutely,  divided  into  pathogenetic  and  non-pathogenetic. 
Every  organism,  even  the  most  harmless,  when  injected  subcutaneously  in 
sufficiently  large  doses,  will  produce  an  inflammatory  lesion.  Again,  an 
organism  may  be  harmless  to  one  species  of  animal  and  virulent  to  another ; 
harmless  to  one  individual  and  virulent  to  another ;  or  in  the  same 
individual  harmless  under  certain  conditions,  virulent  under  others. 
There  are  organisms  which,  when  injected  into  an  animal,  in  reasonable 
quantities,  make  no  attempt  at  proliferation,  but  from  the  moment  of 
inoculation  steadily  decrease  in  number  without  producing  any  symptoms 
of  intoxication.     Such  organisms  are  non-pathogenetic. 

Nature  of  infection. — The  following  are  the  known  and  recognised 
pathogenetic  organisms  capable  of  infecting  man : — Bacilli  of  anthrax, 
diphtheria,  glanders,  tubercle,  leprosy,  typhoid  fever,  tetanus,  malignant 
oedema  ;  and  of  Baltic  fever — the  pyogenetic  cocci,  including  the  pneumo- 
coccus  and  gonococcus,  the  vibrio  of  cholera,  besides  others  whose  exact 
position  is  as  yet  more  or  less  ill  defined.  For  a  number  of  diseases  which 
are  probably  infective,  the  bacteria  have  not  as  yet  been  discovered,  e.g. 
syphilis,  measles,  scarlatina,  variola,  and  certain  other  exanthemata. 

Organisms  in  general,  and  especially  the  pathogenetic  species,  may  be 
divided  into  'parasitic  and  saprophytic  organisms.  The  former  are  such  as 
are  capable  of  growing  in  living  tissues ;  the  latter  thrive  in  or  on  dead  or 
devitalised  matter.  Amongst  the  parasites,  some,  under  certain  conditions, 
may  do  well  in  or  on  dead  matter,  and  conversely  amongst  the  saprophytes 
there  are  some  which,  under  certain  conditions,  are  capable  of  growth  and 
proliferation  in  living  tissues ;  these  organisms  are  the  facultative  sapro- 
phytes and  facultative  parasites  respectively.  Since  most  pathogenetic 
organisms  grow  in  ordinary  laboratory  media,  it  is  evident  that  they  are 
mostly  facultative  saprophytes;  but  there  is  great  diversity  of  opinion 
regarding  their  ability  to  thrive  on  such  soils.  An  organism  which 
cannot  grow  on  dead  matter  is  an  obligatory  parasite,  and  one  which  can- 
not grow  on  living  tissues  an  obligatory  saprophyte.  There  are  but  few 
obligatory  parasites.  However  relative  the  terms  saprophytic  and  para- 
sitic necessarily  must  be,  it  is  of  importance  to  adhere  to  them.  Many 
organisms  may  grow  on  the  different  mucous  membranes,  or  on  the 
skin  as  saprophytes,  i.e.  they  there  vegetate  on  the  secretions  or  dead 
cells,  but  do  not  penetrate  into  the  living  tissues,  and  for  the  time  being- 
are  not  parasitic.  Thus  the  pneumococcus  is  frequently  found  on  the 
buccal  or  tracheal  mucous  membrane,  where  it  grows  as  a  saprophyte  in 
the  saliva  or  mucus  without  producing  its  active  toxine,  or  evincing 
any  tendency  to  infiltrate  the  underlying  tissues.  Similarly  the  Strep- 
tococcus pyogenes  is  found  on  the  tonsils  and  elsewhere  as  a  harmless 
inhabitant,  Staphylococci  alhi  and  aurei  vegetate  on  the  skin,  and  in  the 


5 4  GENERAL  PA  THOL OGY  OF  DISEASE. 

sebaceous  follicles ;  and  all  sorts  and  conditions  of  micro-organisms  lead  a 
saprophytic  and  atoxic  existence  in  the  cavity  of  the  alimentary  canal. 
Some  change  occurs,  either  in  the  micro-organism  itself  or  in  its  surround- 
ings, which  causes  it  to  manufacture  its  toxine,  and  possibly  at  the  same 
time  to  invade  the  underlying  tissues.  This  change  may  be  an  alteration 
of  the  medium  in  which  the  organisms  grow,  for  we  know  that  the 
yeast  cell,  for  example,  can  grow  on  gelatin  without  manifesting  its 
fermentative  activity;  it  merely  vegetates;  but  on  transferring  it  to  a 
glucose  solution,  it  at  once  begins  to  form  alcohol.  Again,  organisms 
capable  of  secreting  diastatic  enzymes  will  often  refuse  to  do  so  if  albumin 
be  present  in  the  medium  in  which  they  grow ;  they  require  for  their 
diastatic  activity  free  oxygen  and  carbon  in  the  form  of  carbohydrates. 

An  organism  may  therefore  for  a  long  time  simply  vegetate  harm- 
lessly, and  then  suddenly,  by  a  process  which  may  be  compared  to  fermen- 
tation, it  may  produce  toxine ;  and  the  latter,  on  being  absorbed  into  the 
lymphatic  and  heeniic  circulation,  will  produce  symptoms  of  disease,  i.e. 
the  organism  becomes  pathogenetic.  The  organism  in  its  new  character 
may  invade  the  tissues  and  become  parasitic,  or  it  may  remain  sapro- 
phytic, and  grow  on  the  surface  of  the  skin  or  mucous  membranes. 
Saprophytic  organisms  may  therefore  be  exquisitely  pathogenetic  if  they 
multiply  rapidly  enough  and  manufacture  toxines  in  sufficient  quantity  to 
produce  either  local  changes  or  general  intoxication.  Thus  it  may  be 
granted  that  the  Bacillus  coli  communis  and  anaerobic  organisms  of  certain 
kinds  are  normally  present  in  the  intestinal  tract  in  limited  numbers ; 
these  may  for  some  reason  or  another  increase  enormously  in  number,  and 
while  still  remaining  in  the  lumen  of  the  intestine  elaborate  a  large 
amount  of  toxine,  this  leading  to  grave  symptoms  of  collapse  and  prostration, 
and  to  diarrhoea  and  enteritis.  On  the  other  hand,  organisms  may  find 
their  way  into  the  intestines  from  without,  as  for  instance  the  cholera 
vibrio,  which  may  grow  and  multiply  on  the  mucosa  without  invading  it, 
and  as  a  saprophyte  produce  a  copious  amount  of  poison,  which,  on  being 
absorbed,  leads  to  the  most  serious  symptoms. 

Streptococci  which  vegetate  on  the  tonsils  in  a  harmless  form,  or  as 
atoxic  saprophytes,  may  become  exquisitely  parasitic,  and  invade  the 
tissues  of  the  tonsil ;  their  toxines  may  be  absorbed,  and  fever  with  other 
grave  symptoms  result ;  nay,  they  may  find  their  way  into  the  lymphatics 
and  the  general  circulation,  and  produce  a  general  septicaemia.  Pneumo- 
cocci,  through  the  changes  produced  by  cold  and  exposure,  may  change 
from  harmless  saprophytes  to  most  virulent  parasites,  produce  remote  and 
secondary  inflammatory  foci  and  even  septicsemia  and  ulcerative  endo- 
carditis. Pathogenetic  organisms,  indeed,  act  either  as  saprophytes  or  as 
parasites,  according  as  they  lie  on  or  in  the  tissues  of  the  body. 

It  is  a  common  error  to  suppose  that  because  an  organism  is  found  inside 
some  space,  eavity,  tube  or  duct  of  the  human  body,  it  lives  in  the  tissues  or  in 
the  body.  In  all  cavities  or  spaces  in  direct  communication  with  the  outer 
world,  the  same  organisms  as  occur  in  the  outer  world  may  be  found.  Indeed, 
unless  there  exist  special  preventive  measures,  those  body  cavities  which  are  in 
direct  communication  with  the  outside  must  always  contain  bacteriar  The 
mouth,  the  alimentary  and  respiratory  tracts,  and  the  pores  of  the  skin  are  all  in 
direct  communication  with — in  fact,  from  a  bacteriological  point  of  view,  they 
represent  simply — the  outer  world,  and  organisms  existing  outside  must  often 
find  their  way  into  these  body  spaces.  It  is  impossible  to  prevent  the  entrance 
of  bacteria  to  the  mouth,  even  if  none  but  sterilised  food  be  taken.     The  air  con- 


A  CTION  OF  INFE  CTIVE  BA  CTERIA.  5  5 

tains  organisms,  both  such  as  are  capable  of  producing  disease,  and  such  as  are 
harmless.  The  organisms  which  find  their  way  into  the  nose,  mouth,  and  larynx 
include  some  undoubtedly  pathogenetic  forms,  as  for  instance  the  micro- 
organisms of  pneumonia  and  suppuration ;  but  though  they  enter  the  body,  they 
remain  there  as  a  rule  without  causing  any  lesions ;  pathogenetic  bacteria  are 
frequently  inhaled,  but  the  diseases  which  they  are  capable  of  producing  do  not 
ensue.  These  organisms  enter  the  body,  not  its  tissues,  and  they  thrive  in  the 
secretions  and  on  the  mucous  membranes  lining  the  various  body  cavities.  The 
resistance  of  healthy  tissues,  and  the  absence  of  predisposing  influence,  prevent 
the  pathogenetic  organisms  present  leading  anything  more  than  a  harmless 
vegetative  existence.  The  bacillus  of  tuberculosis  in  rare  cases  has  been  found  in 
the  nasal  mucous  membrane  of  individuals  attending  upon  consumptives,  giving  , 
rise,  however,  to  no  harmful  results,  so  long  as  it  was  outside  the  tissues  on  the 
mucous  membrane.  But,  on  the  other  hand,  the  micrococcus  of  pneumonia, 
which  lay  harmlessly  on  the  mucous  membrane,  after  a  drenching  or  a  chill  may 
assume  a  virulent  character,  invade  the  lung  tissues,  and  in  some  cases  even  the 
circulation. 

Action  of  infection. — Infection  may  therefore  be  parasitic  or 
saprophytic,  according  as  the  disease-producing  organisms  live  in  the 
tissues  or  upon  the  tissues  in  dead  or  dying  matter.  Bacteria  manu- 
facture their  toxines  wherever  they  grow,  i.e.  infection  is  accompanied 
by  intoxication,  and  it  is  the  latter  which  produces  the  really  serious 
changes  and  symptoms.  The  results  of  intoxication  may  be  local  or 
remote,  or  both.  Thus  in  diphtheria  the  local  changes  in  and  on  the 
tonsils  are  accompanied  by  the  symptoms  of  diffusion  of  the  diphtheria 
poison  over  distant  parts  of  the  body.  This  remote  intoxication  again 
may  be  general  or  selective.  Thus  in  hectic  or  suppurative  fever  there 
is  a  general  intoxication,  while  in  tetanus  the  specific  toxine  singles 
out  the  motor  cells  of  the  spinal  cord,  and  in  diphtheria  the  toxine 
particularly  selects  the  peripheral  nerves  and  their  trophic  centres.  The 
infection  itself  may  be  (a)  local  or  (&)  progressive.  If  local,  the  bacteria 
remain  at  the  seat  of  infection,  where  they  may  or  may  not  multiply. 
Examples  of  local  infections  are  tetanus  and  diphtheria.  If  the  infection 
be  progressive,  it  may  spread  (a)  by  continuity,  as  for  instance  in  a 
spreading  erysipelas,  or  it  may  spread  (b)  by  metastasis,  which  again  may 
be  (1)  haemic  or  (2)  lymphatic,  i.e.  the  organisms  may  be  carried  to  distant 
parts  by  the  blood  stream  or  by  the  lymph  channels.  When  organisms 
enter  the  blood  stream,  after  the  manner  of  emboli,  they  may  be  deposited, 
and  so  lead  to  a  secondary  focus,  or  they  may  multiply  in  the  blood  and 
cause  a  general  blood  infection,  i.e.  a  septicaemia.  In  many  infective 
diseases,  such  as  typhoid  fever,  small  masses  of  bacteria  may  invade  a  blood 
vessel,  through  an  ulcerated  wall ;  if  they  multiply  in  the  blood,  the  result 
is  a  septicaemia,  but  they  may  either  die  or  they  may  be  carried  away  as 
emboli  into  the  bone  marrow  or  elsewhere,  and  there  produce  a  secondary 
focus  or  a  metastatic  deposit.  The  changes  produced  by  an  infection  are 
(1)  local  and  (2)  general.  The  local  action  of  a  micro-organism  shows 
itself  either  as  an  acute  inflammation  or  as  a  more  chronic  process,  which 
may  be  one  of  continued  inflammation,  suppuration,  or  ulceration,  or  one 
of  chronic  fibrosis  (the  so-called  chronic  inflammation).  These  local 
changes  are  produced  by  the  bacteria  and  their  various  poisons,  and, 
broadly  speaking,  the  infective  organisms  and  their  toxines,  unless  they  kill 
the  tissues  outright,  cause  them  to  respond  by  one  or  other  of  two  re- 
actions— (a)  inflammation  or  (b)  proliferation  of  the  connective  tissue. 
So  far  as  our  present  knowledge  goes,  in  man  and  other  warm-blooded 


5 6  GENERAL  PA THOL OGY  OF  VI SEA SE. 

animals,  the  pathogenetic  germs  can  act  in  no  other  direction ;  they 
are  restricted  to  the  connective  tissues  as  their  proper  field  of  action, 
which  they  irritate  by  means  of  their  poisons,  it  may  be  into  a  serous, 
fibrinous  or  purulent,  a  catarrhal  or  necrotic  inflammation,  or  into  a 
reparative  proliferation.  The  effects  which  may  be  observed  in  epithelial 
tissues  are,  whether  these  be  degenerative,  desquamative,  or  even  prolifer- 
ative, secondary  to  the  changes  occurring  in  the  connective  tissues. 

The  local  changes  are  mainly  produced  by  the  non-specific  bacterial  toxines, 
the  general  symptoms  of  intoxication  by  absorbed  specific  poisons,  although  they 
(see  later)  may  also  produce  specific  local  changes,  giving  to  the  local  inflam- 
matory or  proliferative  changes  a  more  or  less  specific  appearance.  Thus  the  local 
inflammation  of  diphtheria  is  specific,  as  much  as  it  is  necrotic  and  fibrinous,  and 
is  accompanied  by  symptoms  and  changes  partly  general  and  partly  specific,  which 
are  due  to  an  intoxication  by  the  general  and  specific  toxines  of  the  diphtheria 
bacillus.  In  pneumonia  the  local  inflammation  is  characterised  by  its  croupous 
nature,  and  is  accompanied  by  specific  symptoms,  which  are  due  to  the  absorption 
of  the  specific  pneumotoxin,  superadded  upon  those  due  to  intoxication  with 
the  general  poisonous  substances. 

The  general  action  of  infective  germs  is  explained  by  the  absorption  of 
poisonous  substances.  It  is  necessary  to  distinguish  between  the  changes  due  to 
intoxication  with  the  general  bacterial  poisons,  and  those  due  to  intoxication 
with  specific  toxines.  The  latter  produce  highly  characteristic  symptoms,  which 
may  be  repeated  in  the  experimental  animal  by  infecting  it  with  the  specific 
poison.  From  diphtheria  cultures  Martin  has  obtained  poisonous  bodies 
which,  inoculated  into  rabbits,  reproduce  the  ideal  picture  of  diphtheria  intoxica- 
tion, together  with  the  characteristic  anatomical  lesion;  from  the  organs  and 
blood  of  children  who  died  with  diphtheria  the  same  bodies  were  separated. 
The  specific  toxine  of  tetanus  has  also  been  separated,  but  up  to  the  present, 
few  others.  The  general  symptoms  of  infective  processes  are  more  or  less  the 
same  for  the  different  diseases — fever,  diarrhoea,  wasting,  respiratory  and  cardiac 
trouble,  leucocytosis  and  inflammation.  Centanni  has  separated  a  poison  (pyro- 
toxin,  closely  allied  to  the  proteins)  from  various  bacterial  cultures  (pneumococci, 
staphylococci,  streptococci,  anthrax,  typhoid,  tetanus,  diphtheria,  and  other 
bacilli),  which  both  chemically  and  in  its  physiological  action  appears  to  be 
identical  in  all.  "When  injected  into  the  animal,  it  sets  up  all  the  above- 
mentioned  general  changes.  Bacterial  intoxication  is  evidently  not  a  simple 
process,  and  it  is  necessary  to  clearly  distinguish  between  the  sets  of  symptoms 
and  changes  produced  by  general  poisons  and  those  due  to  specific  toxines. 

The  mechanical  action  of  bacteria  in  infective  processes  must  not  be  alto- 
gether left  out  of  sight,  although  it  is  of  less  moment  than  their  chemical  action. 
Bacterial  emboli  may  lead  to  vascular  obstruction,  or  the  blood  may  be  so  teeming 
with  micro-organisms  in  septicaemia  that  the  circulation  is  seriously  interfered 
with.  This,  however,  only  occurs  during  the  last  days,  or  it  may  be  horns, 
of  life. 

A  specific  pathogenetic  organism  is  one  which,  on  finding  access  to  the  body 
or  its  tissues  under  proper  conditions,  always  produces  the  same  disease,  this 
property  not  being  shared  by  any  other  pathogenetic  organism.  Thus  tetanus 
and  diphtheria  are  examples  of  truly  specific  infections,  their  specificity  depend- 
ing on  the  fact  that  the  bacilli  of  diphtheria  and  tetanus  manufacture  highly 
specialised  poisons  (possessing  characteristic  physiological  action  by  which  they 
may  be  recognised),  which  are  not  produced  by  other  pathogenetic  organisms. 
There  are  lesions  and  appearances  which  clinically  we  cannot  distinguish  from 
each  other,  and  yet  the  bacterial  flora  may  vary  in  individual  cases,  as  for 
instance  infective  endocarditis  may  be  caused  by  pneumococci,  staphylococci,  or 
streptococci,  and  even  other  organisms.  A  morbid  process  which  can  be  caused 
by  several  organisms  is  not  a  specific  lesion,  nor  is  the  organism  specific  for  that 


RESUL  TS  OF  INFE CTION.  5  7 

lesion.  Thus  a  malignant  pustule  may  be  caused  by  the  anthrax  bacillus 
(and  this  is  the  rule),  but  streptococci  may  also  give  rise  to  it.  Again, 
erysipelas  is  a  clinical  term  used  for  a  disease  accompanied  by  certain  local 
changes  and  general  symptoms.  Here  the  Streptococcus  pyogenes  is  usually 
found,  but  occasionally  other  organisms.  Furthermore,  the  streptococcus  may  pro- 
duce various  lesions,  varying  from  a  circumscribed  inflammation  on  the  one 
hand  to  the  most  serious  septicaemia  on  the  other.  The  term  specific,  therefore, 
can  hardly  be  applied  in  the  present  state  of  our  knowledge  to  any  lesion  which 
is  purely  inflammatory,  and  is  not  accompanied  by  a  characteristic  form  of 
intoxication.  What  is  clinically  one  and  the  same  disease  may  often  be  caused 
by  a  number  of  organisms,  although  perhaps  one  particular  organism  is  more 
generally  found  in  association  with  that  lesion.  It  is  the  same  with  other 
irritants ;  many  organic  or  inorganic  poisons  produce  the  same  obvious  effect 
when  administered  to  the  body,  and  it  is  only  by  a  careful  chemical  examination 
that  the  nature  of  the  irritant  can  be  detected.  Nitric  acid  is  absolutely  different 
from  hydrochloric  acid  chemically,  yet  the  effects  of  these  two  acids  on  the  tissues 
and  the  body  generally  are  clinically  identical.  The  physician  or  surgeon  gives  a 
name  to  a  clinical  lesion,  and  the  pathologist  has  to  investigate  the  flora  of  such 
lesion.  If  one  and  the  same  organism  occurs  with  the  lesion,  then  it  is  specific; 
but  if  more  than  one  organism  is  found,  then  the  term  specific  is  no  longer  applic- 
able. Curative  sera  used  therapeutically  act  specifically,  i.e.  an  antistreptococcus 
serum  is  powerless  against  the  pneumococcus.  Hence,  while  dealing  with  an  in- 
flammatory lesion,  which  clinically  may  be  a  cellulitis  or  a  well-defined  process, 
but  the  bacterial  association  of  which  cannot  with  certainty  be  predicated,  it  is 
necessary  to  make  a  bacteriological  investigation,  and  use  the  antistreptococcus 
serum  only  where  streptococci  are  present.  In  infective  diseases,  then,  the 
clinical  diagnosis  must  always  be  supplemented  or  corrected  by  bacteriological 
observation,  the  methods  of  the  laboratory  being  carried  to  the  bedside  wherever 
and  whenever  this  is  possible.  It  must  be  understood  that  the  name  which  has 
been  given  to  a  disease  or  a  lesion  cannot  govern  or  decide  its  pathology.  The 
exact  or  objective  diagnosis  of  an  infective  disease  often  can  be  made  only  by 
means  of  a  bacterioscopic  examination,  and  just  as  a  physician  tests  the  urine  of 
any  renal  case  for  albumin,  so  he  must  also  search  for  bacteria  in  the  sputum, 
urine,  blood,  or  tissues,  and  apply  other  methods,  such  as  the  serum  diagnosis  of 
typhoid  fever.  Clinical  pathology  in  all  its  branches — i.e.  histology,  bacteriology, 
and  chemistry,  based  on  good,  sound,  and  quick  methods — has  now  become  one  of 
the  most  important  factors  in  diagnosis  and  prognosis.  No  diagnosis  of  tuberculosis, 
diphtheria,  gonorrhoea,  actinomycosis,  malaria,  typhoid  fever,  however  certain  the 
clinical  signs  and  symptoms,  should  be  made  without  being  supported  by  a 
bacterioscopic  and  microscopic  examination ;  and  if  there  is  any  doubt  at  all,  as 
often  there  must  be,  which  experience  and  opinion  cannot  at  once  remove,  an 
appeal  must  be  made  to  hard  facts,  as  demonstrated  by  the  platinum  needle  and 
the  test  tube,  or  on  the  microscopic  slide. 

Results  of  infection. — The  pathologist  may  find  that  one  and  the 
same  ■  organism  may  cause  a  series  of  different  clinical  morbid  conditions, 
or  that  one  and  the  same  clinical  condition  is  produced  by  a  number  of 
organisms.  He  finds,  however,  that,  disregarding  the  mode  of  inoculation 
and  animal  resistance,  the  nature  of  an  infection  varies  (1)  with  the  dose 
of  germs  injected,  (2)  with  their  virulence,  and  (3)  with  the  different 
forms  and  species  of  organisms  which  enter  the  body  either  at  the  same 
time  or  in  quick  succession. 

1.  The  number  of  pathogenetic  bacteria  may  be  so  small  that  the 
defensive  mechanism  of  the  tissues  is  sufficient  to  cope  with  them;  a 
slightly  larger  dose  may  produce  merely  a  local  inflammatory  lesion,  a  still 
larger   dose  a   diffuse  or  progressive  lesion,  with  or  without  metastatic 


5S  GENERAL  PATHOLOG  Y  OF  DISEASE. 

deposits,  and  a  further  increase  a  fatal  septicaemia.  Thus  comparatively 
few  staphylococci  may  lead  to  a  furuncle,  which,  as  the  numbers  in- 
crease, may  develop  into  a .  boil,  carbuncle,  cellulitis,  accompanied  by 
suppurating  glands,  pysemic  abscesses,  and  finally  septicaemia.  Again, 
so  few  streptococci  of  a  given  constant  virulence  may  be  injected 
into  the  rabbit's  ear  that  nothing  results,  or  only  a  slight  local 
lesion;  if  more  be  injected  there  will  be  marked  erysipelas,  and  if  still 
more,  septicaemia. 

2.  The  virulence  of  an  organism  may  be  so  powerful,  that  even 
small  numbers  will  produce  a  septicaemia ;  if  it  be  less  virulent,  a  small 
number  will  lead  to  a  diffuse  or  metastatic  lesion;  if  still  further 
reduced  in  virulence,  merely  a  local  inflammatory  lesion;  a  larger 
dose,  a  diffuse  inflammation ;  and  a  still  larger  dose,  septicaemia ;  and, 
lastly,  the  organism  may  be  so  weak  that  even  a  large  dose  will  be 
without  effect.  These  considerations  plainly  demonstrate  how  it  is 
that  one  and  the  same  pathogenetic  organism  may  lead  to  clinically 
diverse  lesions. 

3.  At  the  seat  of  infection  several  pathogenetic  organisms  may  occur 
together.  Thus  in  a  suppurative  focus  a  mixture  of  pyogenetic  cocci  may 
usually  be  found;  in  diphtheria,  streptococci  frequently  accompany  the 
Klebs-Loffler  bacillus;  whilst  in  tetanus  there  is  an  infection  with 
both  tetanus  bacilli  and  pyogenetic  cocci.  There  are  mixed  infections,  if 
the  various  organisms  have  obtained  their  footing  simultaneously.  The 
mixed  infection  may  make  its  influence  felt  in  three  directions — (a)  the 
various  organisms  work  independently  of  one  another,  as  for  instance 
in  actinomycosis,  where  pyogenetic  organisms  produce  ulceration  and  the 
actinomyces  goes  on  unmolested ;  (b)  one  organism  may  exert  an  attenuating 
influence  on  the  other,  as  may  be  seen  in  anthrax,  where  pyococci  weaken 
and  diminish  the  virulence  of  the  anthrax  bacillus;  (c)  the  organisms 
working  together  in  symbiosis,  each  may  exalt  the  virulence  of  the  other, 
as  in  tetanus.  These  possibilities  rest  on  sound  experimental  basis,  and 
must  be  kept  in  mind  during  treatment.  In  diphtheria,  death  is  often 
due  to  a  septicaemia  produced  by  the  streptococcus ;  and  in  tuberculosis 
the  ravages  of  the  streptococcus  may  require  as  much  consideration  as 
the  tubercular  mischief. 

Secondary  infection,  where  a  fresh  infection  is  grafted  upon  the 
original  lesion,  must  be  carefully  distinguished  from  mixed  infection. 
Thus,  during  the  course  of  an  attack  of  typhoid  fever,  measles,  scarlatina,  or 
variola,  inflammatory  and  suppurative  processes,  such  as  erysipelas, 
abscesses,  osteomyelitis,  necrosis  and  endocarditis,  often  appear,  all 
of  which  are  caused  by  pyogenetic  organisms;  again,  diphtheria  may 
appear  in  the  course  of  scarlet  fever  or  measles,  or  tuberculosis  after 
pneumonia  or  measles;  and  yet  again  a  tuberculous  process  in  the 
lung  becomes  ulcerative  on  account  of  the  streptococcus  obtaining 
access  to  the  caseous  tissues.  In  most  cases  of  secondary  infection, 
pyogenetic  cocci  are  the  causal  agents ;  they  are  always  about  and 
easily  gain  access  to  the  already  diseased  tissues.  Secondary  infections 
depend  (1)  upon  the  presence  in  or  near  the  diseased  body  of  pathogenetic 
organisms ;  (2)  upon  the  diminished  local  or  general  resistance  of  the 
tissues  already  weakened  by  the  primary  infection ;  (3)  upon  the  opening 
up  of  fresh  paths  of  infection  by  the  original  lesion,  which,  causing 
defects  and  lesions  in  the  vessels,  opens  a  ready  portal  for  the  organisms 
lying  in  ambush. 


GENERAL  PREDISPOSITION.  59 


Peedisposition. 


In  the  laboratory  it  is  found  that  some  animals  fall  a  ready  prey 
to  the  activity  of  certain  bacteria,  while  others  are  capable  of  resisting  • 
even  large  doses:  some  animals  are  susceptible  or  predisposed,  others 
are  insusceptible  or  resistant.  A  predisposition  to  an  infection  may 
be  natural,  acquired,  or  inherited.  Animals  differ  greatly  in  their 
susceptibility :  thus  guinea-pigs  and  mice  may  be  infected  even  by  a  few 
anthrax  bacilli,  wdiile  it  requires  a  larger  number  for  rabbits ;  for  rats  a  still 
larger  dose ;  and  for  dogs  exceedingly  large  doses ;  hens  are  altogether 
refractory.  Similarly,  animals  differ  greatly  in  their  susceptibility  towards 
tuberculosis :  guinea-pigs  are  extremely  susceptible ;  mice  and  dogs  are 
almost  refractory.  Natural  predisposition  is  therefore  a  relative  quantity 
— an  animal  may  be  said  to  be  susceptible  when  it  is  readily  infected  by 
any  ordinary  method  of  inoculation,  without  previous  preparation  and  with 
small  or  moderate  doses  of  pathogenetic  organisms.  It  must  be  mentioned 
that  an  animal  which  possesses  but  little  predisposition  to  an  infection 
with  bacteria  may  yet  be  extremely  sensitive  to  the  action  of  the  poison 
manufactured  by  the  bacteria.  Thus  Gamaleia  has  shown  that  animals 
which  can  resist  the  living  vibrio  Metchnikovi,  can  easily  be  killed  by  the 
toxic  products  of  this  vibrio,  and  certain  animals  which  resist  an  infection 
with  pure  cultures  of  the  tetanus  bacillus  succumb  to  the  action  of  their 
toxine. 

Natural  predisposition  may  be  the  property  of  a  species  or  of  a  race  :  thus  all 
guinea-pigs  are  susceptible  to  anthrax  or  tuberculosis ;  the  dark  races  are  less 
disposed  to  yellow  fever  than  are  white  men.  On  the  other  hand,  it  may  be 
individual,  i.e.  certain  members  of  a  species  or  a  race  are  found  to  be  pre- 
disposed to  an  infection.  Age,  weight  and  colour,  time  and  season,  and  certain 
unknown  factors  or  idiosyncrasies,  all  appear  to  play  a  part.  After  a  certain 
age,  many  infective  fevers  lose  their  deadliness.  Tuberculosis  is  commoner  in 
people  with  certain  complexions  than  with  others,  but  normal  man  is  little  pre- 
disposed to  tuberculosis  and  leprosy,  though  it  is  comparatively  easy  for  him  to 
acquire  the  disposition,  at  any  rate,  to  tuberculosis. 

It  is  of  the  utmost  importance  to  keep  in  mind  that  many  infective 
diseases  may  be  staved  off  by  protecting  the  natural  resistance.  In  the 
laboratory  it  is  easy  to  produce  an  artificial  susceptibility.  This  acquired 
predisposition  may  be  general  or  local,  according  as  the  resistance  of  the 
whole  animal  or  only  of  some  part  or  tissue  is  reduced. 

General  predisposition  may  be  established  by  conditions  which 
produce  merely  a  general  effect  on  the  body — hunger  and  thirst,  fatigue,  over- 
exertion and  exhaustion,  continued  loss  of  blood  and  hydremia,  and  changes 
in  temperature  and  in  food.  Starving  pigeons,  thirsting  hens,  and  exhausted 
rats  are  readily  infected  with  anthrax ;  anasmic  rabbits  succumb  more  readily 
to  the  staphylococcus  than  normal  ones;  the  warmed  frog,  the  cooled  hen,  and 
the  herbivorous  rat  all  succumb  to  anthrax.  Numerous  examples  could  be 
cited  to  prove  how  easy  it  is  by  means  of  the  most  general  disturbances  of 
conditions  which  must  always  exist  in  poor,  overcrowded  communities,  to 
break  down  a  natural  resistance  and  establish  a  predisposition.  Certain 
deadly  and  distressing  infective  lesions  can  be  kept  at  bay  only  by 
removing  the  general  conditions  which  may  lead  to  a  predisposition. 

Many  epidemic  diseases,  such  as  cholera,  where  contagion  plays  an 


6o  GENERAL  PATHOLOGY  OF  DISEASE. 

unimportant  part,  invariably  play  havoc  with  the  poorer  classes,  living  in 
conditions  of  filth,  hunger,  and  overcrowding,  and  the  same  is  probably  also 
true  of  the  plague.  Individual  resistance  is  broken  down  by  exhaustion, 
continued  and  excessive  hard  work,  and  by  prolonged  poisoning  with 
alcohol.  A  slight  pyogenetic  lesion  in  those  debilitated  in  this  manner 
may  assume  alarming  proportions,  and  even  end  fatally.  A  predisposition 
thus  acquired  may  again  be  removed  by  attending  to  the  causes  and 
improving  the  general  health. 

Other  more  special  or  well-defined  causes  of  lesions  may,  however,  produce  or 
establish  a  general  predisposition.     The  immediate  effect  of  a  serious  operation, 
such  as  removal  of  the  spleen,  is  a  lowering  of  the  general  resistance  ;  the  presence  of 
sugar  in  the  tissues,  as,  for  instance,  in  artificial  diabetes,  renders  many  animals 
susceptible  to  lesions  which  they  can  resist  in  normal  conditions,  e.g.  phloridzin 
feeding   renders  mice   susceptible  to   glanders.       It  is  a  well-known   fact  that 
persons  suffering  from  diabetes  are  prone  to  pyogenetic  lesions,  such  as  boils, 
carbuncles,  and  gangrene ;  and  Minkowsky  showed  that  dogs,  after  excision  of  the 
pancreas,  frequently  fall  victims  to   suppuration.     Clinically  it  is    known  that 
disease  of  vital  organs,  such  as   the  liver,  kidneys,  and  heart,  predisposes  the 
afflicted  to  infections,  and  aggravates  the  course  of  an  infection  :  the  susceptibility 
of  patients  suffering  from  renal  disease  to  erysipelas  and  inflammatory  lesions  is 
almost  proverbial.     Certain  poisons  administered  either  subcutaneously  or  by  the 
mouth,  or  even  by  inhalation,  are  capable  of  breaking  down  the  natural  immunity 
of  an  animal.     Amongst  such  poisons  may  be  mentioned  alcohol,  chloral,  and 
chloroform ;  further,  the  hemolytic  poisons,  such  as  hydracetin,  phenylhydrazin, 
pyrogallie  acid ;  and,  thirdly,  bacterial  poisons.     The  resistance  of  an  animal  against 
one  organism  may  often  be  destroyed  by  infecting  it  with  the  chemical  products 
of  another  microbe,  and  concurrent  inoculations  of  two  organisms  will  often  lead 
to  successful  infection.       Thus  rabbits   will  succumb   to  quarter-evil  if,  simul- 
taneously  with    the    bacilli,    the    chemical    products    of    the    B.   jyrodigiosun, 
Proteus  vulgaris,  or  staphylococcus  be  administered ;  and  the  tetanus  bacillus  can 
be  rendered  extremely  pathogenetic  for  animals  capable  of  resisting  the  simple 
infection,  by  associating   it  with    such  common  forms    as    the   B.    coli,  the  B. 
prodigiosus,  and  various  pyococci.     The  deleterious  effect  of  poison   absorption 
on   the   course   of   an  infection  has  long  been    recognised.     Thus  in  a  case  of 
erysipelas  or  other  pyogenetic  lesion,  the  physician  or  surgeon  begins  his  treatment 
by  administering  a  purgative  to  clear  away  the  poisonous  substances  which  are 
present  in  the  intestinal  tract. 

Local  predisposition. — It  is  found  that  certain  organisms,  injected 
into  the  tissues  of  an  animal,  die  very  shortly  without  doing  any  harm. 
Under  ordinary  conditions  the  tissues  at  the  seat  of  inoculation  react 
well  enough  with  their  natural  defensive  mechanisms  to  destroy  the 
organisms.  In  order  that  they  may  gain  a  foothold,  the  defences  of  the 
tissues  must  be  weakened  or  abolished ;  experimentally,  this  can  be  done 
in  many  ways.  Thus,  chemical  poisons  do  not  necessarily  always  produce 
a  general  predisposition  ;  their  effect  may  be  purely  local.  For  instance,  if 
tetanus  spores  be  injected  into  the  tissues  of  a  guinea-pig  with  a  little 
lactic  acid,  tetanus  results ;  while,  without  the  acid,  no  harm  would  have 
come  of  the  injection.  Concurrent  inoculation  may  act  in  the  same  way. 
Hence  it  appears  that  the  conditions  just  mentioned  may  affect  the- body 
in  two  or  three  different  ways : — (a)  They  may  weaken  the  tissues  at  the 
seat  of  infection,  so  that  the  organisms  have  a  chance  of  surviving; 
(b)  they  may  destroy  the  general  resistance  of  the  body,  so  that  the 
organisms  or  their  toxines  become  generally  diffused ;  or  (c)  a  local  pre- 
disposition having  been  established,  and  an  opportunity  having  been  given 


INHERITED  PREDISPOSITION.  61 

to  the  organisms  to  elaborate  their  toxines,  these  gradually  undermine  the 
general  resistance.  It  is  neither  easy  nor  desirable  to  keep  local  and 
general  predisposition  too  strictly  distinct.  The  natural  defences  of  the 
tissues  may  be  broken  through  by  contusions,  necrosis,  or  injuries.  On 
inoculating  the  Staphylococcus  aureus  into  the  circulation,  an  osteomyelitis 
will  result  more  readily  if  the  bone  has  previously  been  injured,  an 
infective  endocarditis  if  a  cardiac  or  aortic  valve.  The  injection  of  tetanus 
spores  will  produce  fatal  lockjaw  if,  during  the  injection,  the  tissues  be 
roughly  handled,  or  the  underlying  bone  be  fractured.  Here  the  organisms 
are  merely  supplied  with  the  conditions  necessary  for  their  survival  by 
the  disturbance  of  the  delicately  balanced  equilibrium.  Clinically,  this  is 
fully  recognised  in  the  case  of  tuberculosis,  pneumonia,  acute  osteomyelitis, 
and  infective  endocarditis ;  in  the  last-mentioned  disease  pre-existing  val- 
vular lesions  are  common.  Injuries  to  the  joints  in  "  white  swelling,"  the 
influence  of  cold  and  circulatory  disturbances  as  predisposing  causes,  are 
too  well  established  to  require  further  comment.  Local  lesions,  then,  may 
prove  great  sources  of  danger,  both  during  infective  processes,  and  also  as 
predisposing  causes,  and  therefore  require  the  fullest  consideration  and 
attention  of  the  physician. 

It  must  be  remembered  that  the  normal  resistance  of  animals  against  toxines 
may  also  be  reduced.  Thus  guinea-pigs  which  had  been  immunised  against 
the  vibrio  of  Massowah  (cholera)  or  the  B.  coli  were  more  susceptible  to 
tetanus  toxine  than  normal  animals,  and  those  treated  with  pneumotoxin  were 
more  susceptible  to  diphtheria  toxine.  Again,  wasted  or  tuberculous  animals 
succumb  more  readily  to  diphtheria  intoxication.  In  this  connection  it  is 
interesting  to  note  that  in  many  fatal  cases  of  diphtheria  active  tuberculous 
changes  (broncho-pneumonia  or  meningitis)  or  concurrent  infections  (scarlatina 
or  measles)  are  found  as  complications. 

Inherited  predisposition. — Can  an  infection  be  inherited  ?  Chil- 
dren are  frequently  born  showing  signs  of  infective  disease  acquired  as  it 
is  being  born  or  before  birth.  Thus,  instances  of  ophthalmia  neonatorum 
are  common,  and  congenital  tuberculosis,  although  rare,  is  by  no  means  un- 
known; even  the  typhoid  bacillus  has  been  found  in  the  organs  of  the 
foetus.  The  foetus  therefore  may  acquire  a  microbic  disease  either  in  utero 
or  during  its  passage  through  the  vagina  into  the  world.  The  latter  mode 
of  infection  cannot  possibly  be  looked  upon  as  hereditary  transmission ;  it 
is  a  simple  case  of  contagion.  The  infected  mother  infects  her  child.  A 
little  reflection  will  show  that  intra-uterine  infection  is  not  to  be  regarded 
as  a  true  inheritance.  The  pathogenetic  organism  is  never  inherited  by  the 
unimpregnated  ovum,  but  in  utero  the  ovum  or  foetus  is  infected  by  germs 
which  have  passed  from  a  lesion  in  the  maternal  tissues,  and,  after 
traversing  the  placental  filter,  have  found  a  suitable  soil  in  the  foetal 
organs.  Hence  micro-organisms  may  be  transmitted,  but  they  are  not 
inherited.  It  is  found  that  bacteria  do  not  easily  pass  through  the 
placental  barrier,  and  that,  when  they  do  so,  there  is  generally  a  lesion  in 
the  placenta — a  haemorrhage,  i.e.  a  flaw  in  the  filter,  or  the  special  organisms, 
such  aa  tubercle  or  glanders  bacilli,  are  capable  of  producing  destructive 
lesions.  In  the  case  of  susceptible  species,  the  offspring  of  tuberculous 
mothers  often  contain  virulent  tubercle  bacilli  in  their  tissues.  These 
may  remain  dormant  in  the  tissues  for  weeks  and  months,  and  then  pro- 
duce fatal  tuberculosis.  Intra-uterine  infection  through  the  mother  is 
therefore  possible.  It  may  occur  in  man  as  well  as  in  animals,  but  it  is 
an  infection,  and  not  an  inheritance,  and  depends  on  some  accident  or 


6 2  GENERAL  PA  THOL O GY  OF  DISEASE. 

other.  It  is,  however,  important  to  remember  that,  though  the  offspring 
of  a  tuberculous  mother  may  be  born  with  virulent  tubercle  bacilli  in  its 
tissues,  it  may  take  months,  and  even  years,  for  tuberculosis  to  manifest 
itself.  The  predisposition  is  still  absent  at  birth,  and  only  as  it  gradu- 
ally comes  on  can  the  dormant  bacilli  gain  the  upper  hand,  and  produce 
their  specific  effect.  Again,  the  inherited  predisposition  may  be  specific, 
i.e.  the  mother's  tissues  having  been  predisposed,  the  ovum  may  be  similarly 
predisposed,  or  this  specific  predisposition  may  have  been  transmitted 
through  the  father,  in  which  case  frequently  phthisis  appears  in  the 
offspring  about  the  same  age  as  it  did  in  the  parent.  On  the  other  hand, 
the  inherited  predisposition  may  be  general,  depending  merely  on  the 
general  weakness  and  debility  of  the  parents,  the  infant  then  being 
susceptible  to  infections  generally. 

As  far  as  the  mammalia  are  concerned,  there  is  no  evidence  that  an  ovum  is 
ever  infected  before  or  during  conception.  Careful  experiments  on  guinea-pigs 
are  entirely  opposed  to  such  a  view.  Heredity,  then,  concerns  itself  only  with 
predisposition,  and  never  with  infection. 


Contagion. 

To  the  practical  physician  it  is  obviously  a  matter  of  the  utmost  im- 
portance to  know  how  an  infectious  disease  spreads,  i.e.  whether  or  no  an 
infected  person  may  prove  a  source  of  danger  to  the  community.  Formerly, 
careful,  but  hardly  intelligent  or  intelligible,  distinctions  were  drawn  between 
infectious  and  contagious  diseases.  Now,  however,  new  definitions  have 
been  drawn  up.  The  meaning  of  the  term  "  infective  "  has  been  explained 
at  length.  A  disease  is  said  to  be  contagious  when  it  is  transmissible 
from  the  affected  to  the  non-affected,  not  necessarily  to  the  healthy,  because 
the  predisposition  which  is  required  for  a  successful  transmission  may  be, 
and  generally  is,  a  morbid  condition.  It  is  better  to  avoid  the  term  "  con- 
tagious" and  to  speak  of  transmissible  infective  diseases. 

First,  it  must  be  made  quite  clear  that  though  infective  lesions,  due  to 
microbes,  may  be  transmissible,  they  are  not  necessarily  so. 

Secondly,  there  are  degrees  of  transmissibility ;  in  some  cases  a  predis- 
position is  required,  in  others  not.  Transmission  evidently  can  only  take 
place  through  contact,  but  such  contact  may  be  direct  or  indirect.  When 
there  is  direct  contact,  then  the  materies  morbi  must  be  transferred 
directly  from  the  diseased  person  to  the  victim  by  touch,  inoculation, 
inosculation,  or  inhalation ;  when  contact  is  indirect,  then  the  diseased 
individual  has  left  the  materies  morbi  upon  some  intermediate  object, 
whence  it  finds  its  way  into  the  body  of  a  fresh  victim ;  or,  expressing  it  in 
symbolic  language,  when  a  disease  is  directly  transmissible,  it  passes  from 
A  to  B,  B',  B",  etc. ;  when  it  is  indirectly  transmissible,  it  passes  from  A 
through  X,  X',  X",  etc,  to  B,  B',  B",  etc. 

Classification. — Infective  diseases,  then,  may  be  placed  in  two  large 
groups — (a)  transmissible  diseases,  and  (b)  diseases  not  transmissible.  The 
latter  include  relapsing  fever  and  malaria.  Certain  of  the  transmissible 
diseases  are  produced  by  obligatory,  or  almost  obligatory,  parasitic  organ- 
isms, e.g.  gonorrhoea,  syphilis,  and  rabies,  although  the  bacteriology,  if  such 
there  be,  of  the  two  latter  diseases  is  as  yet  undetermined.  Diseases  due 
to  such  organisms  can  only  be  acquired  by  direct  contact ;  a  predisposition 
is  probably  unnecessary. 


CONTAGION.  63 

Others  of  these  diseases  are  due  to  organisms  which  possess  the  faculty 
of  surviving  or  thriving  outside  the  animal  body — facultative  saprophytes. 
With  them  transmission  may  be  by  direct  as  well  as  by  indirect  contact ; 
but  the  greater  their  saprophytic  faculty,  the  more  important  becomes 
transmission  by  indirect  contact.  Amongst  the  diseases  which  are  due  to 
facultative  saprophytes  are  measles,  variola,  scarlatina,  glanders,  tuber- 
culosis, leprosy,  diphtheria,  plague,  and  traumatic  and  pyogenetic  infections, 
though  as  yet  nothing  is  known  of  the  germs  of  measles,  variola,  and 
scarlatina,  or  of  the  saprophytic  history  of  the  leprosy  bacillus.  In  some 
of  these  diseases,  e.g.  variola  and  scarlatina,  direct  contact  plays  the  more 
important  part ;  in  others,  such  as  tuberculosis,  where  direct  and  indirect 
contact  play  an  equally  important  part,  contact  segregation  is  not  sufficient 
to  stamp  out  the  disease.  In  fact,  its  sufficiency  is  directly  proportional 
to  the  saprophytic  nature  of  the  disease-producing  germ.  Thus,  although 
it  is  for  practical  purposes  sufficient  for  variola  and  scarlatina,  it  is  quite 
insufficient  for  tuberculosis  and  diphtheria.  Many  of  these  diseases  require 
a  predisposition,  and  it  is  found  that  measures  may  be  taken  to  remove 
this.  The  strong  and  healthy  are  not  harmed  by  the  tubercle  bacillus, 
while  for  the  predisposed  tuberculosis  is  an  easily  transmissible  disease. 
General  hygienic  improvement,  coupled  with  vigorous  disinfection,  has 
already  done  much  to  reduce  the  mortality  from  tuberculosis,  and  in 
many  countries  it  has  stamped  out  leprosy. 

Thirdly,  certain  diseases  are  caused  by  facultative  parasites,  organisms 
which  are  highly  saprophytic,  such  .as  the  bacilli  of  enteric  fever  and 
anthrax,  and  the  vibrio  of  cholera.  Here  direct  contact  may  be  practically 
neglected.  There  is  generally  an  extensive  common  area  of  infection 
in  which  the  disease  germs  thrive  under  saprophytic  conditions,  and  whence 
they  infect  a  large  community ;  these  diseases,  therefore,  are  usually 
epidemic.  Here  the  eradication  or  disinfection  of  the  common  source  of 
infection  is  of  primary  importance,  and  the  diseased  should  not  be 
allowed  to  continue  to  disseminate  the  specific,  pathogenetic  organisms. 
Quarantine  must  be  enforced,  and  all  ejecta  disinfected.  Mere  personal 
segregation,  however,  without  destruction  of  the  source  of  infection,  is 
absolutely  useless. 

Lastly,  certain  infective  lesions  are  due  to  more  or  less  purely  sapro- 
phytic organisms,  e.g.  various  forms  of  diarrhoea.  Here  direct  contact  need 
not  be  taken  into  consideration,  and  our  attention  must  be  directed  to  the 
fons  et  origo  bacterice,  food,  or  soil,  etc. 

A  little  reflection  will  make  it  clear  upon  what  points  the  degree  of  trans- 
missibility  depends — the  parasitic  or  saprophytic  nature  of  the  organism,  in 
question  ;  its  distribution  in  space ;  its  resistance  outside  the  body ;  the  readiness 
with  which  infection  is  produced,  i.e.  whether  or  no  a  predisposition  is  required, 
whether  any  form  of  inoculation  is  suitable,  or  whether  special  forms  are 
necessary. 

An  infective  disease  is  endemic  when  it  occurs  in  a  given  locality,  this 
area  never  being  free  from  it.  In  such  case — (1)  the  infective  organism 
must  possess  a  markedly  saprophytic  nature ;  (2)  there  must  be  suitable 
external  conditions  which  keep  up  the  source  of  infection ;  and  (3)  the 
surroundings  must  be  such  that,  if  a  predisposition  is  required,  it  is  always 
provided.  Cholera,  for  instance,  is  endemic  in  Lower  Bengal,  and  leprosy 
over  many  parts  of  India. 

Epidemic  diseases  are  those  which  within  a  short  space  of  time  affect  a 


64  GENERAL  PATHOLOGY  OF  DISEASE. 

large  number  of  individuals ;  they  may  visit  areas  where  they  were  almost 
unknown,  or  areas  where  they  are  endemic.  Infective  diseases  which  are 
quickly  spread  by  direct  contact,  especially  when  a  predisposition  is  hardly 
necessary,  such  as  variola  and  scarlatina,  are  likely  to  become  epidemic ; 
similarly,  diseases  which  are  rapidly  diffused  from  a  common  source  of 
infection,  as  for  instance  cholera  or  enteric  fever ;  and,  lastly,  diseases 
which  are  easily  transmitted  by  indirect  contact,  such  as  plague.  The 
epidemic  character  of  a  disease  depends  simply  upon  the  facility  and 
rapidity  of  infection  and  transmission,  and  therefore  if  in  an  area  where 
a  disease  is  always  at  home  for  some  reason  or  another,  conditions  arise 
which  render  general  infection  easy,  the  endemic  disease  suddenly  breaks 
out  with  epidemic  force. 

Immunity. 

The  converse  of  predisposition  is  immunity  or  insusceptibility ;  it  also 
may  be  natural,  acquired,  or  inherited.  Natural  immunity  or  resistance  is 
innate,  and  little  is  known  of  its  why  and  wherefore. 

In  this  connection  it  is  necessary  to  distinguish  carefully  between  an 
infection  and  an  intoxication  caused  by  a  pathogenetic  organism.  The 
distinction  must  not,  however,  be  carried  too  far ;  it  must  be  remembered 
that  there  is  no  intoxication  without  a  previous  infection,  the  period  passing 
between  the  moment  of  infection  and  the  first  symptoms  of  intoxication 
being,  by  the  physician,  usually  called  the  incubation  period.  During  this 
period  the  bacterium  which  has  entered  the  body  or  its  tissues  is  actively 
producing  its  lesions  and  its  toxines,  a  certain  time,  however,  elapsing 
before  its  effects  can  be  recognised.  The  incubation  period  is  at  an  end 
clinically,  either  when  the  lesion  is  of  such  size  or  appearance  that  it  no 
longer  escapes  the  senses,  or  when  the  intoxication  has  become  evident. 
But,  again,  just  as  there  is  no  intoxication  without  infection,  so  there  is 
no  infection  without  some  intoxication,  and  it  is  often  the  latter  which, 
assuming  a  recognised  type,  ends  the  incubation  period.  This  period  is 
characterised  by  headache,  malaise,  and  rise  of  temperature,  and  eventually 
the  accumulated  effect  of  the  toxine  absorption  gives  a  temperature  chart 
or  a  series  of  symptoms  which  are  satisfactorily  diagnosed  as  the  onset. 
An  acute  infective  fever  may  be  compared  to  a  forced  immunisation. 

The  first  inoculation  produces  no  recognisable  symptoms  in  the  animal,  but  as 
the  inoculations  are  frequently  repeated  in  ever-increasing  strength,  the  animal 
suffers,  often  becomes  extremely  ill,  and  perchance  dies,  if  an  overdose  is  given. 
This  is  a  dangerous  method,  involving  loss  of  animals.  It  is,  however,  nature's 
method,  and  is  best  illustrated  by  the  processes  observed  in  typhoid  fever.  The 
effects  of  the  early  lesions  are  not  recognised,  except  that  there  is  headache,  etc.; 
as  more  Peyer's  patches  and  lymph  follicles  become  involved  the  disease  is 
recognised,  and  the  fever  rises  and  the  temperature  may  become  alarmingly  high. 
Each  fresh  infection  of  a  Peyer's  gland  may  be  compared  to  an  inoculation  given  for 
the  purpose  of  artificial  immunisation,  and  if  it  is  not  carried  to  excess  there  comes 
a  period  where  sufficient  immunity  is  established,  the  temperature  comes  down, 
and,  should  there  be  a  relapse,  the  prognosis  is  good.  Much  therefore  happens 
during  the  so-called  incubation  period ;  it  is  the  period  of  careful  immunisation 
which  gives  the  initial  hnmunity.  In  some  infective  fevers  complete  immunity 
sets  in  with  a  crisis,  which  means  that  the  patient  has  become  proof  against  the 
toxine  produced  by  the  organisms  causing  the  disease,  and  that  the  condition  is  a 
pure  infection.  Often,  however,  there  is  a  mixed  or  secondary  infection,  and 
then  a  crisis  is  out  of  the  question,  because,  while  the  patient  has  become  immune 
with  regard  to  the  main  or  initial  infection,  he  is  still  susceptible  to  the  other. 


IMMUNITY.  65 

In  typhoid  fever,  for  instance,  when  the  immunisation  against  the  B.  typhosus  is 
practically  complete,  the  pyogenetic  organisms  and  the  ulcers  have  still  to  he 
reckoned  with ;  hence  the  suppuration  temperature  which  occurs  before  the  fever 
subsides. 

Natural  immunity  from  infection  must  be  distinguished  from 
natural  immunity  from  intoxication. 

The  former  may  be  characteristic  of  the  individual,  of  the  species 
or  a  variety  of  that  species,  of  a  whole  genus  or  even  of  a  whole  class. 
Cold-blooded  animals  are,  with  few  exceptions,  normally  insusceptible  to 
the  infections  of  warm-blooded  animals.  In  warm-blooded  animals — birds 
and  mammals — each  species  or  variety  must  be  studied  by  itself;  the 
natural  immunity  from  various  infections  seems  to  have  been  distributed 
in  an  arbitrary  manner,  although  no  doubt  its  establishment  is  based  upon 
natural  and  artificial  selection,  evolution,  and  heredity.  Even  amongst 
the  members  of  a  susceptible  species  immune  individuals  may  be  met  with 
(idiosyncrasy). 

Natural  immunity  from  intoxication  as  a  rule  goes,  within  certain 
limits,  with  immunity  from  infection,  and  especially  in  the  case  of 
organisms  which  are  pre-eminently  intoxicative,  such  as  the  tetanus 
bacillus,  which  does  its  deadly  work  by  sending  out  its  toxine — all  the  more 
dangerous  because  it  has  a  special  affinity  for  the  delicate  nervous  sub- 
stance of  the  central  nervous  system — from  the  seat  of  infection.  The  same 
may  with  some  reservations  be  said  of  the  diphtheria  bacillus.  Hence 
immunity  from  diphtheria  and  tetanus  must  imply  immunity  from  both 
infection  and  intoxication,  but  mainly  from  the  latter.  In  some  cases 
animals  may  resist  infections  with  various  organisms,  and  yet  be  sus- 
ceptible to  their  poisons. 

Racial  immunity. — The  dark  races  are  more  resistant  to  yellow 
fever  and  haematozoal  diseases  than  others ;  and  it  appears  also  that  the 
native  of  India  enjoys  some  resistance  against  typhoid  fever.  A  disease 
when  it  first  makes  its  appearance  in  a  race  is  often  extremely  deadly 
in  its  effects.  The  existence  of  individual  immunity  has  long  been 
recognised. 

In  man  natural  immunity  from  intoxication  is  most  important  in  the  case  of 
those  pathogenetic  bacteria  which,  under  normal  conditions,  exist  in  the  body,  and 
a  natural  immunity  from  infection  is  most  important  in  the  case  of  those  patho- 
genetic bacteria  which  enter  the  body  more  or  less  accidentally.  Certain  definite 
changes  occur  in  a  naturally  immune  animal  subsequent  to  an  inoculation.  Should 
the  quantity  of  bacteria  he  small,  little  is  noticeable ;  the  organisms  are  rapidly 
destroyed ;  when  larger  quantities  are  used,  inflammation  ending  in  the  annihila- 
tion of  the  microbe  without  suppuration  ensues.  Excessive  doses  may  produce 
suppuration  and  death  even  in  the  immune  animal,  this  being  the  result  of 
poisoning  by  the  intracellular  substances,  so  that  from  this  point  of  view  it  may 
he  said  that  no  animal  is  absolutely  immune.  In  the  immune  animal,  then, 
organisms  which  are  pathogenetic  to  susceptible  individuals  behave  as  harmless 
organisms,  and  they  are  incapable  of  further  proliferation,  although  the  poison 
contained  in  the  cell  substance,  becoming  free  with  the  death  of  the  bacteria,  may 
induce  symptoms  of  intoxication.  The  immune  animal  is,  however,  as  a  rule  able 
to  withstand  this  poison,  reacting  fully  to  doses  which  would  kill  susceptible 
animals.  The  normal  defensive  mechanisms  of  the  tissues  are  sufficient  to  cope 
with  the  bacteria  and  their  poisons,  without  calling  upon  the  cells  to  display 
special  chemical  activities  ;  in  fact,  the  tissues  treat  them  as  ordinary  irritants,  and 
destroy  them  by  simple  inflammation,  accompanied  and  followed  by  all  the 
ordinary  phenomena  of  that  condition.  The  bacteria  cannot  proliferate,  because 
vol.  1. — 5 


66  GENERAL  PA THOLOG  Y  OF  DISEASE. 

the  inflammatory  reaction  destroys  them  as  it  would  destroy  irritant  necrotic 
tissue ;  their  poisons  can  do  but  little  harm,  partly  because  inflammation  hinders 
absorption,  favours  dilution,  and  attenuates  the  poison,  which  to  begin  with  is 
but  little  dangerous  to  the  immune  tissues.  The  tissues  and  fluids  of  the  body 
of  most  animals  possess  a  certain  amount  of  bactericidal  and  antitoxic  power,  and 
this  power  is  greatly  increased  by  the  leucocytes  and  their  products ;  if,  therefore, 
an  animal  is  so  constituted  that  it  will  react  to  an  infection  by  reactive  and 
reparative  inflammation,  there  is  but  little  danger  of  a  fatal  issue,  and  in  an 
immune  animal  an  infection  produces  merely  a  small  local  inflammatory  change 
which  has  no  tendency  to  spread.  A  certain  intensity  of  irritation  is  required 
before  the  vascular  tissues  respond  by  inflammation ;  if  the  irritant  is  too  weak, 
the  noxious  matter  is  got  rid  of  by  the  ordinary  normal  processes,  whether  these 
be  regenerative,  chemical,  phagocytic,  or  mechanical;  and  if  the  number  of 
bacteria  and  the  amount  of  poison  be  relatively  small,  the  tissues  of  the  immune 
animal  destroy  the  invaders  at  once  without  making  any  call  upon  an  inflam- 
matory reaction.  The  identical  process  may  be  seen  in  susceptible  animals 
inoculated  with  a  subminimal  dose.  If  this  be  extremely  minute,  the  bacteria 
are  destroyed  at  once  without  the  slightest  inflammatory  reaction,  a  bigger  dose 
will  lead  to  inflammation  ending  in  repair,  while  the  true  minimal  lethal  dose 
rouses  the  tissue  to  an  attempt  at  an  inflammatory  resistance,  which  is,  however, 
unsuccessful.  It  is  obvious,  then,  that  an  animal  is  immune  when  its  tissues 
are  so  constituted  that  even  comparatively  large  doses  of  bacterial  poisons  have 
no  further  action  beyond  stimulating  them  to  immediate  or  inflammatory  repair  ; 
and  the  degree  of  resistance  is  measured  by  the  maximum  dose  of  bacterial 
poison  to  which  the  animal  can  respond  with  reparative  reaction. 


Immunisation. 

When  a  rabbit  (which  is  an  animal  strongly  predisposed  to  anthrax)  is 
inoculated  subcutaneously,  intravenously,  or  intraperitoneally,  with  com- 
paratively few  anthrax  bacilli,  it  succumbs  to  anthrax  septicaemia.  Now, 
if  it  be  treated  in  such  a  manner  that  a  similar  quantity,  and  even  a 
larger  quantity  of  the  anthrax  virus  is  borne  without  serious  harm,  it  is 
said  to  have  been  immunised  or  protected.  Immunity  cannot  be  under- 
stood without  a  sound  knowledge  of  the  methods  of  immunisation,  which 
may  be  either  non-specific  or  specific. 

Non-specific  immunisation. — An  animal  may  be  protected  against 
an  infection  with  a  given  organism  by  the  use  of  bacteria  belonging  to 
entirely  different  species  or  genera.  Thus,  as  shown  by  Klein  and 
others,  if  a  guinea-pig  be  inoculated  intraperitoneally  with  the  B.  typhi 
abdominalis,  the  animal  becomes  immune  against  intraperitoneal  injec- 
tions of  totally  different  bacteria.  Again,  previous  treatment  with  the 
streptococcus  of  erysipelas  {Streptococcus  pyogenes),  or  sterilised  culture 
of  B.  pyocyaneus,  induces  in  certain  animals  an  immunity  against  anthrax. 
In  such  cases  the  immunity  is  most  marked  if  the  inoculation  be  made 
in  the  situation  at  which  the  immunising  injection  has  been  administered. 
This  process  of  immunisation  is  probably  a  chemical  one,  because,  instead 
of  the  living  cultures  used  for  the  purpose  of  immunisation,  sterilised 
cultures,  i.e.  their  chemical  products,  may  be  used.  Again,  the  immunity 
produced  is  merely  temporary,  disappearing  in  small  animals  in  one  to 
four  weeks.  A  specific  immunity  against  cholera,  produced  by  previous 
injections  of  cholera  vibrios  or  their  products, lasts  for  months;  a  vicarious 
immunity  produced  by  previous  injections  of  the  B. pyocyaneus,  for  instance, 
lasts  only  two  to  three  weeks.     Thirdly,  a  specific  immunity  is  general, 


IMMUNISATION.  67 

i.e.  after  the  animal  has  been  immunised  it  does  not  matter  where  the 
test  dose  is  injected,  but  in  a  vicarious  immunity  the  best  results  are 
always  obtained,  when  the  test  dose  is  injected  in  the  same  situation  as 
the  immunising  dose. 

Pfeiffer,  Issaeff,  and  others  have  shown  that  instead  of  living  or  dead 
cultures  of  micro-organisms,  such  solutions  as  broth,  urine,  saline,  or  other 
chemical  solutions,  when  injected  into  the  peritoneal  cavity  of  an  animal,  set  up 
a  peritoneal  immunity  identical  with  that  just  described.  This  appears  to  favour 
the  theory  that  the  process  is  purely  chemical.  Others  have  used  extracts  of 
tissues  or  cells,  as  for  instance  thymus  and  testicular  extracts,  yeast  nuclein, 
normal  blood  serum  of  animals,  spleen  extract,  spermin,  etc.,  all  of  which, 
to  a  certain  degree,  inhibit  bacterial  growth,  and  it  was  imagined  that  they 
exerted  an  antiseptic  or  disinfectant  action.  Here  again  comparatively  large 
quantities  are  necessary,  and  the  immunity  is  merely  temporary  and  local.  Normal 
blood  serum,  in  quantities  altogether  insufficient  to  act  as  a  disinfectant,  injected 
into  the  peritoneal  cavity  of  a  guinea-pig,  will  protect  it  against  a  choleraic  intra- 
peritoneal infection.     Hence  the  immunising  action  is  not  directly  bactericidal. 

If  an  animal  be  immunised  against  the  cholera  vibrio  by  repeated 
injections  with  this  organism,  its  serum  gradually  acquires  a  strong 
protective  action,  i.e.,  a  small  quantity  inoculated  into  an  unprotected 
animal  will  render  it  immune  against  a  lethal  dose  of  choleraic  material. 
Supposing  that  1  c.c.  of  serum  of  a  normal  animal,  when  injected  into  the 
peritoneal  cavity  of  a  guinea-pig,  would  protect  this  animal  against  the 
lethal  dose  of  cholera  vibrios,  a  fraction  of  1  c.c.  (say  y1^  c.c.)  of  serum 
from  the  immunised  animal  will  produce  the  same  effect.  Now  the 
normal  serum  would  also  have  protected  a  guniea-pig  against  intra- 
peritoneal injections  of  other  organisms,  e.g.  the  B.  coli.  But  although 
yV  c.c.  of  the  serum  from  the  immunised  animal  is  sufficient  to  im- 
munise against  the  lethal  dose  of  cholera  vibrios,  1  c.c.  of  this  serum  is 
required  to  protect  against  the  B.  coli.  The  effect  produced  by  immuni- 
sation with  bacteria  (or  their  products)  then  is  specific.  Again,  if  a 
guinea-pig  be  injected  intraperitoneally  several  times  with  B.  pyocyaneus, 
it  would  be  immune  from  the  effects  of  intraperitoneal  injection  of  B. 
prodigiosus.  Its  serum  now  has  a  specific  action  against  B.  pyocyaneus, 
but  hardly  any  against  the  B.  prodigiosus.  This  shows  that  although  the 
injection  of  one  organism  may  produce  a  marked  local  immunity  against 
another  organism,  the  general  effect  on  the  tissues  is  specific.  The  most 
noteworthy  local  changes  which  occur  during  the  process  of  non-specific 
immunisation  is  a  local  leucocytosis,  accompanied,  however,  by  a  slight 
general  hasmic  leucocytosis,  indicating  a  slight  general  effect.  Fever  and 
local  inflammation,  which  are  both  frequently  produced,  are  reactions  of 
the  utmost  importance. 

All  the  different  processes  mentioned  so  far,  do  not  act  as  directly  germicidal ; 
they  produce  changes,  most  marked  at  the  seat  of  inoculation,  but  not  absent 
elsewhere,  and  these  changes  are  followed  by  a  temporary  diminution  of  the 
predisposition  towards  infections  generally.  It  has  been  shown  experimentally 
that  a  general  immunity  may  be  produced  in  an  animal  by  injecting  it  with  drugs, 
enzymes,  or  albuminous  substances  which  produce  a  marked  hasmic  leucocytosis ; 
and  it  has  actually  been  recommended  that  pilocarpine  injections,  which  produce 
a  considerable  increase  in  the  number  of  white  corpuscles  in  the  blood,  should 
be  used  therapeutically.  Further,  it  is  generally  recognised  that  in  many  infective 
fevers  the  number  of  leucocytes  in  the  blood  is,  under  certain  conditions,  a  good  index 
as  to  the  progress  of  the  patient  towards  recovery,  i.e.  towards  immunity.     Thus, 


68  GENERAL  PATHOLOGY  OF  DLSEASE. 

with  a  more  or  less  severe  infection,  if  there  is  marked  leucocytosis,  the  reaction 
is  good,  and  prognosis  is  favourable,  while  if  leucocytosis  is  absent  the  reaction 
is  weak,  and  the  chance  of  recovery  is  less.  Probably  other  changes,  as  yet 
unrecognisable,  take  place  in  the  body,  under  the  conditions  now  under  discussion, 
and  along  with  leucocytosis. 

Non-specific  immunity,  the  result  of  a  previous  infection,  has  as  yet  not  been 
observed  in  man;  on  the  contrary,  it  is  a  demonstrable  fact  that  during  con- 
valescence from  one  infective  fever,  an  individual  may  acquire  others  which  run 
their  clinical  course  undisturbed;  and  Dr.  Caiger  says  "the  symptoms  of  one 
disease  are  neither  delayed  in  their  appearance,  nor  mitigated  in  their  severity, 
by  the  presence  of  another,  but  the  characteristics  of  each  are  for  the  most  part 
well  defined,  and  in  some  instances  even  exaggerated."  It  is,  however,  not  the 
relation  between  convalescence  and  fresh  infection  which  is  of  importance,  but 
that  between  complete  recovery  and  fresh  infection.  Animal  experiments  show 
that  all  our  inoculations  in  the  study  of  immunity  must  be  made  when  there  has 
been  a  complete  restitutio  ad  integrum  ;  indeed,  during  convalescence  animals  are 
often  more  highly  susceptible  to  fresh  infections. 

The  treatment  of  peritoneal  tuberculosis  by  mere  drainage  is  well  known  to 
all,  and  there  can  be  no  reasonable  doubt  that  the  success  of  this  procedure 
defends  (as  pointed  out  by  Durham)  upon  this  principle  of  non-specific  pro- 
tection, which  raises  the  resistance  and  destructive  powers  of  the  peritoneal 
membrane. 

A  general  non-specific  immunity  may  further  be  established  by  the 
administration  of  chemical  substances  before  infection.  Thus,  von  Fodor 
and  others  have  shown  that  in  many  animals,  by  raising  the  alkalinity 
of  the  blood,  a  temporary  protection  may  be  effected,  and  it  is  claimed 
that  there  is  a  distinct  relation  between  the  degree  of  alkalinity  of  the 
blood  of  animals  before  and  after  recovery,  and  their  susceptibility. 

A  local  inflammation  will  often  procure  a  local  non-specific  pro- 
tection, the  degree  of  the  latter  varying  directly  with  the  amount  of 
leucocytosis  produced  at  the  seat  of  inflammation.  This  may  account  for 
the  immunising  action  of  the  various  substances  mentioned  above,  local 
inflammatory  lesions  progressing  favourably  towards  repair,  protecting 
against  infection  by  virtue  of  the  leucocytic  and  other  exudative  changes. 
Thus  it  is  well  known  that  granulating  wounds  are  only  with  difficulty 
infected.  Cartwright  Wood  and  Cobbett  have  shown  that  a  simultaneous 
or  previous  inflammation  may  often  produce  a  temporary,  more  or  less 
local,  immunity  to  erysipelas,  which  is  non-specific  in  character.  On  the 
other  hand,  if  leucocytosis  be  absent,  as  for  instance  in  an  cedematous 
inflammation,  there  is,  instead  of  protection,  often  increased  susceptibility. 

The  good  effect  of  inflammation  has  also  been  taken  advantage  of  clinically, 
for  the  purpose  of  curing  chronic  infections  of  a  milder  type,  i.e.  for  the  purpose 
of  establishing  a  local  immunity,  as  in  the  tuberculin  treatment.  On  injecting 
a  patient  suffering  from  lupus  with  tuberculin,  a  local  inflammatory  reaction 
appears  around  the  lupoid  area,  accompanied  by  fever  and  a  general  hsemic 
leucocytosis.  This  local  inflammation  cannot  as  yet  be  explained,  but  cure  or 
local  immunity  undoubtedly  follows  its  appearance  in  certain  cases.  Cantharidin, 
albumoses,  peptones,  and  bacterial  extracts,  all  produce  fever  or  hsemic  leucocytosis, 
affording  further  illustration  of  the  relation  between  leucocytes  and  general 
immunity.  Further,  the  good  effect  of  an  acute  inflammation  upon  a  chronic 
infective  process  may  be  instanced  in  connection  with  the  use  of  blisters, 
fomentations,  and  poultices,  injections  and  applications  of  nitrate  of  silver  or 
sulphate  of  copper,  which,  awakening  a  slumbering  process  into  acuteness,  have 
cured  many  a  lingering  affection.     It  has,  as  yet,  not  been  proved  that  the  rise 


ACTIVE  IMMUNISATION.  69 

of  the  body  temperature  per  se  is  sufficient  to  set  up  either  general  or  local 
non-specific  immunity ;  indeed,  apart  from  the  leucocytic  changes  in  the  blood 
during  an  infective  fever,  the  rise  of  temperature  and  the  increased  metabolic 
activity  may  be  actually  harmful. 

Non-specific  immunity  against  toxines  can  also  be  produced  by  in- 
jections of  different  fluids  into  the  peritoneal  cavity.  Thus  Calmette 
has  shown  that  the  previous  inoculation  of  a  guinea-pig  with  broth,  or 
different  kinds  of  serum,  raises  the  resistance  of  the  peritoneum  against 
toxines. 

The  general  resistance  of  a  tissue  against  bacteria  or  toxines  may  be  artificially 
raised  by  prophylactic  injections  of  various  solutions ;  these  appearing  to  react 
by  producing  a  general  or  local  leucocytosis,  or,  as  in  the  case  of  alkalies,  by 
altering  the  chemistry  of  the  blood.  That  this  latter  point  must  not  be  forgotten, 
is  clear  from  the  experiments  of  Freund  and  Gross,  who  showed  that  the  injection 
of  substances  capable  of  preventing  coagulation  will  render  animals  proof  against 
diphtheria  intoxication. 

Specific  immunisation. — By  specific  immunisation  is  understood — 
(1)  a  treatment  with  a  given  living  micro-organism,  or  its  chemical 
products,  derived  either  from  the  dead  bodies  of  the  micro-organism  or 
held  in  solution  by  the  culture  fluid ;  or  (2)  a  treatment  with  chemical 
substances  derived  from  and  held  in  solution  by  the  blood  or  other  fluid 
of  an  animal  treated  as  in  (1).  In  either  case  the  result  of  the  treatment 
must  be  an  immunity  from  an  infection  with  that  micro-organism,  or  an 
intoxication  with  its  products ;  an  immunity  which  is  specific  in  this 
sense,  that  the  resistance  against  the  organism  in  question,  or  its  toxines, 
has  been  raised  out  of  all  proportion  to  what  would  have  been  brought 
about  had  the  treatment  been  general.  In  the  first  case  the  micro- 
organisms or  their  products  are  administered  to  the  animal,  and  the  latter 
passes  through  an  attack  of  the  infection  or  intoxication,  and  on  recovery 
from  an  illness  of  some  duration  has  acquired  a  marked  protection,  or 
immunity  of  specific  character.  In  tlxe  other  case,  a  portion  of  the 
immunity  acquired  by  one  animal  is  transferred  to  a  normal  and  susceptible 
animal ;  here  the  latter  suffers  no  illness,  it  merely  accepts  the  protection 
for  which  the  other  animal  had  to  struggle.  It  is  evident  that  there  is 
an  essential  difference  between  the  two  methods  of  immunisation ;  and  since, 
in  the  one  case,  the  tissues  must  fight  and  react  visibly,  but  in  the  other 
are  apparently  merely  passive  recipients,  the  first  mode  of  treatment  is 
called  active  immunisation,  the  other  passive  immunisation. 

1.  Active  immunisation. — An  animal  may  be  rendered  either  highly 
infection  proof,  or  highly  toxine  proof;  but  it  must  be  remembered  that  an 
animal  which  has  been  specially  immunised  against  living  virus  possesses 
also  a  certain  amount  of  toxine  immunity,  and  vice  versd. 

(a)  Active  immunisation  against  living  virus  in  the  laboratory  may  be 
brought  about — (1)  by  the  use  of  attenuated  virus ;  (2)  by  inoculation 
with  sublethal  doses  of  bacteria;  (3)  by  changing  the  portal  of  infection; 
(4)  by  injecting  the  chemical  products  of  the  virus.  There  are,  of  course, 
other  methods  of  active  immunisation ;  these  four,  however,  illustrate  the 
principle  underlying  artificial  immunity. 

(1)  Attenuated  virus. — Pasteur  showed  that  an  attenuated  virus  pro- 
duces an  immunity  against  a  stronger  one,  and  pointed  out  that  an 
immunity  against  an  infection  follows  upon  the  administration  of  atten- 
uated micro-organisms.     The  attenuation  must  be  carried  only  so  far  that 


7 o  GENERAL  PA  THOL OGY  OF  DISEA SE. 

the  organisms  still  remain  capable  of  growing  at  the  seat  of  inoculation, 
and  of  producing  a  local  lesion.  The  animal  passing  through  a  mild  form 
of  the  disease  is,  after  complete  recovery,  able  to  resist  a  reasonable  dose 
of  strong  virus.  This  method  is  employed  to  obtain  protection  against 
anthrax,  fowl  cholera,  swine  erysipelas,  and  rabies.  It  is  evident  that, 
having  once  got  the  animal  to  withstand  a  dose  of  strong  virus,  it  may 
be  accustomed  gradually  to  bear  larger  doses  by  repeating  the  injections, 
and  at  the  same  time  gradually  raising  the  virulence  of  the  bacterial 
culture  used.  Beginning,  then,  with  attenuated  virus,  in  order  to  awaken 
the  defensive  powers  of  the  tissues,  and  continuing  with  stronger  and  with 
increasing  doses  of  it,  an  extraordinary  immunity  from  artificial  infection 
may  be  obtained ;  an  immunity  which  is  specific  in  this  sense,  that,  although 
the  treatment  has  temporarily  somewhat  raised  the  general  resistance  of 
the  animal,  the  protection  against  the  virus  used  for  the  purpose  of 
immunisation  is  considerable  and  enduring,  proportionate  to  the  doses 
used,  and  the  virulence  of  the  organisms  employed. 

Attenuation  of  micro-organisms  may  be  produced  in  many  ways,  of  which  the 
following  may  be  mentioned.  By — (a)  growing  them  at  a  raised  temperature 
(anthrax  at  42°  C.) ;  (b)  exposing  them  to  sunlight  (B.  tuberculosis) ;  (c)  desicca- 
tion (bacillus  of  quarter  evil)  ;  (d)  electrolysis  ;  (e)  exposing  them  to  a  raised  atmo- 
spheric pressure;  (/)  bringing  them  into  contact  with  free  oxygen;  (g)  adding 
antiseptics  to  the  cultures ;  (h)  growing  them  for  a  longer  or  shorter  period  in 
test-tubes ;  (i)  by  concurrently  inoculating  another  organism ;  (7i)  by  passing  the 
organism  through  the  animal  body;  and  (Z)  by  attenuating  them  in  vivo  by 
simultaneously  injecting  chemical  substances,  such  as  normal  serum  and  anti- 
septics, which  either  awaken  the  resisting  powers  of  the  tissues  or  diminish  the 
virulence  of  the  organisms.  In  attempting  to  produce  an  artificial  specific 
immunity,  too  much  should  not  be  demanded  from  the  tissues.  They  can 
counteract  a  certain  dose  of  bacteria,  which  naturally  varies  inversely  with  the 
virulence.  An  excessive  dose  of  attenuated  organisms  will  kill  as  certainly  as 
a  small  dose  of  virulent  ones,  unless  attenuation  be  carried  so  far  that  the 
organisms  have  become  absolutely  powerless.  As  the  tissues  are  always  capable 
of  accounting  for  a  certain  number  of  bacteria,  an  active  immunity  from  infection 
may  be  obtained  even  by  beginning  ivith  sublethal  doses  of  virulent  organisms. 

(2)  Sublethal  doses. — It  is  easy  to  immunise  animals  against  typhoid, 
cholera,  or  pyocyaneus  infection,  by  using  a  smaller  dose  than  the  minimal 
lethal  one ;  such  doses,  however,  must  be  sufficient  to  cause  local  changes. 
A  strong  immunity  may  be  quickly  produced  by  giving  repeated  minute 
injections.  Thus,  by  inoculating  a  guinea-pig  intraperitoneally  every  two 
hours  with  -^  to  -^  the  lethal  dose  of  typhoid  bacilli,  an  immunity  is  pro- 
duced against  forty  to  fifty  times  the  lethal  dose  within  twenty-four  hours ; 
this  is  enduring  and  specific  in  the  sense  explained  above,  i.e.,  although 
the  resistance  against  the  typhoid  bacillus  is  raised  forty  or  fifty-fold,  that 
against  other  organisms  is  only  slightly  raised. 

(3)  Change  of  portals  of  infection. — Organisms  often  vary  as  to  the 
effect  they  produce  in  the  body,  according  as  the  injection  has  taken 
place  subcutaneously,  intraperitoneally,  or  intravenously,  etc.  Instead 
of  using  attenuated  virus  or  a  minute  dose,  an  inoculation  of  a  larger 
dose  may  be  given  in  the  least  harmful  situation.  An  animal  can  bear 
a  larger  dose  of  B.  pyocyaneus  subcutaneously  than  intraperitoneally  or 
intravenously,  a  larger  dose  of  typhoid  bacilli  intravenously  than  intra- 
peritoneally, a  larger  dose  of  diphtheria  bacilli  intraperitoneally  than 
subcutaneously. 


ACTIVE  IMMUNISATION.  71 

For  the  three  experimental  methods  of  active  immunisation  above  described, 
analogous  examples  may  be  found  in  medicine.  Thus,  it  is  a  well-known  fact 
that  recovery  from  an  infective  disease  conveys  an  immunity  of  shorter  or  longer 
duration.  This  natural  process  of  immunisation  may  be  compared  to  protection 
by  sublethal  doses.  Vaccination  against  variola  in  all  probability  affords  an 
instance  of  immunisation  by  attenuated  virus,  and  the  old  process  of  variolisation 
illustrates  the  method  of  protection  by  change  of  portal,  as  also  does  Haffkine's 
method  of  anticholera  vaccination. 

(4)  Chemical  products  of  the  bacteria. — Instead  of  using  living  virus  for 
the  purpose  of  immunisation,  either  the  dead  bodies  of  the  bacteria  them- 
selves, or  the  substances  which  are  held  in  solution  by  the  culture  fluid, 
may  be  employed.  It  is  important  to  distinguish  between  immunisation 
by  the  chemical  substances  contained  in  the  bacterial  bodies,  and  im- 
munisation by  the  chemical  substances  found  outside  the  bacterial  bodies. 
As  far  as  the  outward  result  is  concerned,  an  immunity  against  infection 
is  produced  whichever  chemical  substance  is  used ;  but  although  an  animal 
immunised  with  extracellular  chemical  substances  acquires  specific  pro- 
tection, both  against  the  living  bacteria  and  those  extracellular  poisons, 
an  animal  immunised  with  living  or  dead  bacteria  has  but  little,  or  at 
any  rate  considerably  less,  protection  against  these  poisons,  in  spite 
of  its  acquired  immunity  from  an  infection  with  the  living  bacteria 
themselves. 

(b)  Active  immunisation  against  toxines  is  carried  out  either  by  re- 
peated inoculations  of  weak  toxine,  or  of  minute  sublethal  doses  of 
strong  toxine.  It  is  possible  to  establish  a  toxine  immunity,  not  only 
in  the  case  of  bacterial  poisons,  but  also  in  the  case  of  certain  animal 
poisons,  and  some  derived  from  the  higher  plants.  Amongst  the  animal 
poisons  are  snake  venom  and  scorpion  poison ;  amongst  those  of  the 
higher  plants,  abrin,  ricin,  and  robin.  These  toxines  are  chemically,  ap- 
parently, closely  related  to  those  of  bacterial  origin ;  they  all  belong  to  the 
group  of  albuminoid  bodies  and  are  not  alkaloidal  in  nature.  It  is  possible 
to  establish  a  tolerance  against  alkaloids  and  poisons  of  simpler  con- 
stitution (such  as  inorganic  poisons,  arsenic,  etc.).  Tolerance  of  a  poison 
is,  however,  different  from  toxine  immunity;  it  is  acquired,  and  pro- 
gresses, slowly  (while  an  immunity,  although  slowly  acquired,  progresses 
more  quickly),  and  is  accompanied  by  changes  in  the  body  leading  to  the 
production  of  an  antitoxic  serum.  The  fact  that  only  poisons  belonging 
to  the  group  of  toxines  or  enzymes  can  be  used  for  the  purpose  of  obtaining 
an  antitoxic  serum  is  important,  because  it  shows  that  in  this  respect 
there  must  be  some  relation  between  the  chemical  constitution  and  the 
physiological  action.  The  serum  of  an  animal  accustomed  to  large  doses 
of  arsenic,  opium,  or  strychnine,  does  not  become  antitoxic. 

In  the  case  of  tetanus  and  diphtheria,  it  is  possible  to  obtain  a  high  degree  of 
toxine  immunity  by  using  minute  doses  of  toxine,  slowly  and  gradually  increased, 
or  by  first  injecting  subcutaneously  toxine  attenuated  by  the  addition  of  iodine 
solution.  An  initial  toxine  immunity  having  once  been  produced,  it  can  be 
readily  raised  by  repeating  and  increasing  the  doses  of  pure  or  undiluted  toxine. 
In  some  cases  gastric  administration  will  produce  an  active  immunity,  as 
in  the  case  of  abrin  and  ricin,  and  it  is  said  also  of  snake  venom,  tetanus, 
and  diphtheria. 

If  an  animal  be  immunised  with  bacterial  toxines  or  with  bacteria  which  kill 
by  intoxication,  it  becomes  proof  (a)  against  the  corresponding  infection,  as  well  as 
(b)  against  the  intoxication ;  but,  on  the  other  hand,  animals  immunised  with 


72  GENERAL  PATHOLOGY  OF  DLSEASE. 

living  bacteria,  which  generally  kill  by  septicaemia,  become  proof  only  against  the 
infection.  Thus  diphtheria  or  tetanus  bacilli  will  produce  both  a  toxine  and  an 
infection  immunity  ;  diphtheria  toxine,  tetanus  toxine,  pyocyaneus  toxine  will  all  do 
the  same  ;  but  the  living  culture  of  B.  pyocyaneus,  B.  typhosus,  B.  cholerce,  etc., 
will  produce  protection  from  the  living  cultures  only ;  and  even  in  the  first  case  it 
has  been  found,  for  diphtheria  at  least,  that  if  living  cultures  only  be  used,  the  in- 
fection immunity  is  greater  than  the  toxine  immunity,  whilst  if  toxines  are  used 
the  conditions  are  reversed. 

Again,  although  a  single  dose  of  toxine  may  suffice  to  obtain  an  infection 
immunity,  it  may,  and  generally  does,  take  many  doses  to  produce  even  an 
initial  toxine  immunity ;  it  is  therefore  much  easier  to  establish  a  marked 
resistance  against  the  living  organism  than  against  their  toxines, — a  point 
worth  considering  in  the  treatment  of  infective  diseases.  It  is  interesting 
to  note  that  if  an  animal  be  immunised  by  means  of  increasing  doses  of 
living  cholera  or  typhoid  cultures,  a  point  is  at  last  reached  at  which  a 
further  injection  of  living  culture  kills  the  animal.  This  appears  to  be 
because  the  poison  contained  in  the  bacterial  cells,  dissolved  and  destroyed 
in  the  body  of  the  bacteria  immune  animal,  is  liberated,  a  poison  against 
which  the  animal  has  not  been  immunised. 

2.  Passive  immunisation. — We  must  now  speak  of  passive  immu- 
nisation, which  is  based  upon  this  fundamental  law :  Tlie  serum  of  a  speci- 
fically immunised  animal,  vihen  injected  into  another  animal,  confers  upon  the 
latter  an  immunity  from  infection  with  the  organisms  against  lohich  the  first 
animal  had  been  protected.  (1)  The  action  of  this  serum  is  specific,  with  a 
few  limitations  to  be  stated  shortly.  (2)  The  immunising  value  varies 
directly  with  the  degree  of  antitoxine  present  in  the  serum  given.  (3)  The 
blood  of  a  naturally  immune  animal  does  not  possess  the  power  of  an  arti- 
ficially immunised  animal. 

{a)  Passive  immunisation  against  infection. — It  is  quite  immaterial 
by  what  method  an  animal  is  immunised  against  an  infection,  i.e.  whether 
dead  or  living  bacteria  or  their  extracellular  products  be  used ;  so  long 
as  the  animal  is  rendered  highly  bacteria  proof,  its  serum  will  also  acquire 
strongly  immunising  powers.  There  is,  however,  a  difference.  Immunisa- 
tion with  dead  or  living  bacteria  produces  an  antibacterial  serum ;  immu- 
nisation with  extracellular  bacterial  toxines,  one  which  is  both  antitoxic  and 
antibacterial. 

(1)  The  specificity  in  action  of  the  serum  derived  from  immunised 
animals. — In  the  serum  from  an  animal  highly  immunised  against  cholera 
vibrios,  the  serum  has  a  marvellous  preventive  action  against  an  infection 
with  cholera  vibrios,  but  it  must  be  confessed  that  it  also  has  a  marked 
action  upon  infections  with  other  organisms.  Has  it  then  no  specificity  ? 
Certainly  it  has ;  for  even  normal  serum  has  a  general  restraining  influence 
which  is  not  affected  by  the  process  of  specific  immunisation,  which,  how- 
ever, greatly  increases  the  specific  action  of  the  serum.  A  single  example 
will  make  this  clear.  02  c.c.  of  serum  of  a  normal  goat  is  capable,  as 
shown  by  Pfeiffer,  of  counteracting  an  infection  with  2  mgrms.  of  virulent 
vibrios,  and  similarly  against  an  infection  with  2  mgrms.  of  virulent  typhoid 
bacilli.  After  the  goat  has  been  immunised  against  typhoid,  0-005  c.c.  is 
sufficient  to  counteract  2  mgrms.  of  virulent  typhoid  bacilli  while  it  still 
requires  02  c.c.  to  inhibit  2  mgrms.  of  cholera  vibrios ;  and  conversely,  after 
the  goat  has  been  immunised  against  cholera,  0-002  c.c.  suffices  to  neutralise 
2  mgrms.  of  cholera  vibrios,  while  it  still  requires  0-2  c.c.  to  counteract 
2  mgrms.  of  typhoid  cultures.    It  follows,  therefore,  that  the  newly  acquired 


PASSIVE  IMMUNISATION.  73 

antibacterial    substance   is   different   from  the  general  antibacterial  sub- 
stance, and  is  truly  specific. 

(2)  The  immunising  value  of  the  antibacterial  serum  varies  with  the 
degree  of  immunity  produced. — A  single  injection  with  bacterial  toxine  is 
often  capable  of  establishing  an  initial  immunity  from  an  infection  with 
the  lethal  dose  of  living  bacteria,  and  it  has  been  shown  that  this  immunity 
appears  critically,  i.e.,  it  appears  more  or  less  suddenly  after  one,  two,  or 
three  days,  or  even  a  longer  interval.  Again,  the  appearance  of  this  initial 
immunity  is  not  directly  proportional  to  the  amount  of  toxine  used,  i.e.  some 
animals  react  to  smaller  doses  than  others.  Immunity  appears,  therefore, 
after  a  reaction,  which  is  sometimes  short,  sometimes  prolonged,  which  may 
be  called  forth  by  smaller  or  larger  doses  of  toxine.  During  the  initial  stage 
of  immunity,  the  serum  of  the  animal  has  but  little  if  any  antibacterial 
power;  to  obtain  this  it  is  necessary  to  raise  the  initial  immunity,  so  that 
the  animal  can  withstand  many  times  the  lethal  dose.  To  produce  the  ini- 
tial immunity  the  animal  must  be  made  to  react,  the  symptoms  and  signs 
of  reaction  being  local  inflammatory  changes,  fever,  local  and  haemic  leuco- 
cytosis ;  and  to  raise  the  initial  immunity  it  is  necessary  to  increase  the 
dose,  so  that  the  animal  reacts  to  each  inoculation,  because,  as  the 
animal  becomes  immune  its  sensitiveness  becomes  diminished.  If,  for 
instance,  an  animal  be  immunised  with  a  sublethal  dose  of  toxine,  and  this 
same  dose  be  given  for  weeks  and  months,  the  animal  acquires  an  initial 
immunity  against  the  lethal  dose,  but  never  against  many  times  that  dose. 
If,  however,  when  the  initial  immunity  has  been  obtained,  a  larger  dose  be 
injected,  and  then,  when  the  reaction  has  entirely  subsided,  a  larger  dose, 
and  so  on,  the  animal  eventually  acquires  an  immunity  against  many  times 
the  lethal  dose,  and  antibacterial  serum  can  be  obtained. 

An  antibacterial  serum  may  be  obtained  in  two  ways — (1)  dead  or  living  bac- 
teria alone  may  be  injected  in  ever-increasing  doses ;  or  (2)  increasing  doses  of  the 
extracellular  toxin  es  may  be  used.  There  is  this  difference  in  the  result :  the  first 
method  yields  only  an  antibacterial  serum,  while  the  latter  method  yields  a  serum 
which  is  both  antibacterial  and  antitoxic.  In  either  case,  the  immunity  of 
the  animal  becomes  raised,  and  the  power  of  the  serum  for  a  time  becomes  more 
marked,  so  that,  while  to  begin  with  perhaps  1  c.c.  of  serum  was  required  to 
counteract  the  single  lethal  dose,  later  on  0#005  c.c.  will  be  found  sufficient. 

(3)  The  blood  of  a  naturally  immune  animal  does  not  possess  the  power 
of  that  derived  from  an  artificially  immunised  animal. — An  active  immun- 
ity can  only  be  obtained  slowly,  and  requires  a  reaction  on  the  part  of  the 
animal  which  is  being  treated,  and  it  has  been  found  that  an  animal  which 
is  very  sensitive  and  gives  the  highest  reaction  will  also  yield  the  most 
potent  antibacterial  serum.  Therefore  it  is  not  surprising  that  the  serum 
of  naturally  immune  animals  has  no  action  beyond  that  general  action 
against  infection  which  belongs  to  all  forms  of  serum,  though  by  giving  a 
naturally  immune  animal  an  injection  of  the  bacteria  which  are  harmless 
to  its  tissues,  a  specific  antibacterial  serum  of  weak  potency  may  be  ob- 
tained :  this  clearly  proves  the  essential  difference  between  the  two  kinds 
of  serum.  Again,  an  injection  of  immunising  serum  into  a  naturally  im- 
mune animal  will  impart  to  the  serum  of  this  animal  the  new  and  specific 
properties.  All  these  considerations  are  important,  because  they  show 
that  during  immunisation  special  chemical  changes  take  place  which  pro- 
duce conditions  differing  essentially  from  pre-existing  ones.  Artificial 
specific  immunity  cannot  be  a  mere  elaboration  of  the  natural  general 
immunity. 


74  GENERAL  PATHOLOGY  OF  DISEASE. 

Active  immunisation  is  a  process  which,  requires  time  and  patience,  and  a 
marked  reaction  on  the  part  of  the  animal  undergoing  the  process ;  passive  im- 
munisation, on  the  other  hand,  is  quick  and  sudden,  and,  while  working  with 
low  multiples  of  the  lethal  dose,  is  proportional  to  the  amount  of  serum  injected. 
It  is,  however;  not  possible  by  using  the  serum  of  an  immunised  animal  to  transfer 
to  another  animal  the  same  amount  of  resistance  which  the  giver  of  the  serum  has 
slowly  and  laboriously  acquired.  The  passive  immunity  is  at  its  height  almost 
immediately  after  the  injection  of  the  serum,  and  then  gradually  diminishes ;  the 
active  immunity  is  more  lasting. 

(b)  Passive  immunisation  against  toxines. — Just  as  it  is  possible  to 
produce  a  passive  immunity  against  infections,  so  also  in  regard  to  intoxi- 
cations. An  animal  rendered  highly  toxine  proof  yields  a  serum  which  will 
protect  a  susceptible  animal.  (1)  The  action  of  the  serum  is  specific ;  (2)  its 
immunising  value  depends  upon  the  degree  of  immunity  acquired ; x  and 
(3)  naturally  immune  animals  do  not  possess  a  serum  of  the  same  power  as 
that  of  an  artificially  immunised  animal. 

If  antitoxic  serum  be  mixed  with  toxine  in  certain  proportions,  the 
mixture  injected  into  an  animal  remains  harmless — the  poison  has  been 
neutralised;  if  less  serum  be  used,  the  neutralisation  is  partial,  and  the 
animal  succumbs  or  recovers  after  a  prolonged  illness.  The  serum  may  be 
injected  into  the  animal  before,  together  with,  or  after  the  poison,  and  in 
no  case  does  evil  ensue.  The  neutralisation  is  not  a  merely  chemical 
one,  for  the  amount  of  antitoxic  serum  required  for  a  given  dose  of  serum 
varies  with  the  susceptibility  of  the  animal ;  thus  a  mixture  of  toxine  and 
antitoxine  may  be  harmless  for  one  animal,  whilst  it  is  still  fatal  for  a 
more  susceptible  animal.  Tetanus  toxine  with  antitoxine,  mixed  in  such  pro- 
portions as  to  be  no  longer  injurious  to  1  kilo,  of  white  mice,  is  still  toxic 
for  1  kilo,  of  guinea-pigs.  In  the  process  of  immunisation,  then,  the 
condition  of  the  cells  of  the  animal  which  receives  the  serum  is  of  the 
utmost  importance,  and  if  it  requires  a  certain  amount  of  diphtheria  anti- 
toxine to  neutralise  the  lethal  dose  of  diphtheria  toxine  for  a  healthy  guinea- 
pig,  a  larger  dose  of  antitoxine  is  required  for  a  starved  or  weakened  guinea- 
pig.  The  immunity  is  produced  immediately,  and  in  the  healthy  the  anti- 
toxic serum  is  as  harmless  as  the  antibacterial,  or  as  the  normal  serum. 

The  antitoxic  properties  are  acquired  only  some  time  after  immunisation  has 
been  begun,  and  they  remain  at  their  height  only  so  long  as  immunisation  is  con- 
tinued, and  may  finally  vanish,  although  the  animal  may  still  possess  considerable 
protection,  immunity  continuing  without  a  concomitant  antitoxic  power  of  the 
serum.  During  the  process  of  immunisation  it  is  found  that  immediately  after 
each  injection  the  antitoxic  value  falls  slightly,  after  which  it  rises  to  a  higher 
level  than  it  had  previously  reached  ;  whilst,  after  bleeding  an  animal  to  obtain 
its  antitoxine,  the  loss  is  almost  at  once  made  good  by  the  cells  of  the  body,  show- 
ing that  the  production  of  antitoxine  depends  on  cellular  activity. 

To  obtain  an  antitoxic  serum,  toxine  in  ever-increasing  quantities,  and  to 
produce  a  high  antitoxic  potency,  strong  toxines,  must  be  used.  The  antitoxic 
and  antibacterial  substances,  although  they  may  coexist,  are  not  the  same. 
Thus,  in  the  case  of  immunisation  with  the  B.  pyoeyaneus  or  its  toxine,  it  has  been 
shown  by  Wassermann  that  after  immunisation  with  increasing  doses  of  toxine, 
the  serum  contains  both  antibacterial  and  antitoxic  powers  ;  and  that,  if  at  a  given 
moment  the  immunisation  be  continued  with  living  cultures,  the  antibacterial 
power  rises,  while  the  antitoxic  value  falls,  and  may  be  reduced  to  zero ;  and, 
finally,  that  after  immunisation  with  living  cultures,  the  serum  may  be  strongly 

1  This  does  not  hold  good  in  the  same  sense  or  degree  that  it  does  in  the  cases  of  immunity 
against  infections. 


THE  OR  Y  OF  I  AIM  UNIT  Y—NA  TURAL  IMAIUNITY.  7  5 

antibacterial  and  yet  possess  no  antitoxic  powers ;  but  if  it  possesses  antitoxic 
powers,  it  always  possesses  also  antibacterial  powers.  With  a  serum  which  is 
both  antitoxic  and  antibacterial,  it  is  much  more  difficult  to  protect  against  a 
lethal  dose  of  poison  than  against  a  lethal  dose  of  culture.  Roughly  calculated,  it 
requires  100  times  as  much  serum  to  counteract  the  toxine  as  is  required  by  the  virus. 

Specificity  of  antitoxic  serum. — It  has  been  shown,  especially  by 
Calmette,  that  the  serum  of  an  animal  immunised  by  repeated  and  ever- 
increasing  doses  of  one  snake  venom  has  a  preventive  action  upon  the 
poison  of  other  snakes,  and  even  upon  the  poison  of  a  scorpion.  This  state- 
ment, although  challenged  with  regard  to  the  poison  of  Russell's  viper, 
is  in  the  main  apparently  true,  because  of  the  close  chemical  and  physio- 
logical relation  between  the  different  venoms.  Just  as  the  cholera  serum 
will  protect  against  all  the  varieties  of  cholera  vibrios,  so  the  antivenom- 
ous  serum  derived  from  a  cobra-poison  proof  animal  may  be  expected 
to  counteract  all  allied  varieties  of  poison. 

A  feeble  antitoxic  action  may  be  discovered  in  the  serum  of  many  normal 
animals,  in  one  case  against  snake  poison,  in  another  against  diphtheria  toxine,  and 
so  forth,  but  there  is  no  correlation  between  natural  immunity  and  this  power  of 
the  serum.  Again,  Calmette  has  shown  that  an  animal  vaccinated  with  and 
against  abrin,  yields  a  serum  which  has  some  effect  on  diphtheria  toxine  and 
ricin,  although  the  last  observation  is  strenuously  denied  by  Ehrlich.  Certain 
experiments  tend  to  show  that  the  serum  of  animals  immunised  against  certain 
poisons  is  capable  of  acting  against  other  poisons,  but  from  these  it  cannot  be 
concluded  that  antitoxic  serum  is  not  specific,  because  as  yet  there  is  no  serum 
capable  of  counteracting  a  number  of  poisons,  or  even  of  neutralising  two  different 
poisons  with  the  same  energy.  It  appears  that  in  some  cases,  by  the  process  of 
immunisation,  the  serum  is  developed  in  one  particular  direction,  and  occasionally 
also  slightly  in  another,  or  it  may  be  in  several  other  directions.  But  whenever 
a  real  vicarious  action  of  an  antitoxic  serum  upon  another  heterologous  toxine  is 
developed,  as  for  instance  in  the  case  of  snake  venoms,  it  may  be  accepted  that 
there  is  some  close  chemical  and  physiological  relation  between  the  toxines,  an 
assumption  ably  defended  by  Ehrlich.  The  physician,  for  the  present  at  any 
rate,  must  regulate  his  treatment  in  accordance  with  this  faith  in  the  specific 
action  of  antitoxines. 

Theory  of  Immunity. 

Natural  immunity. — What  factors  co-operate  to  render  the  tissues 
so  resistant  that  they  either  remain  unaffected  by  pathogenetic  bacteria  and 
their  toxines,  or  react  against  them  with  their  normal  methods  of  defence1? 
This  resistance  is  not  due  to  any  of  the  folloAving  factors — (1)  absence  of 
nutrient  material  in  the  tissues;  (2)  unsuitable  temperature;  or  (3)  reaction  of 
the  blood  and  lymph.  It  can  be  shown,  however,  that  the  animal  body  possesses 
in  its  fluids  antibacterial  substances,  for,  if  absolutely  harmless  bacilli  be  injected, 
they  die  rapidly,  even  when  protected  from  the  direct  action  of  the  cells ;  and 
further,  the  presence  of  these  substances  in  the  blood  serum  and  different  exuda- 
tions has  been  clearly  demonstrated  by  test-tube  experiments.  There  is,  how- 
ever, no  absolute  correlation  between  the  antibacterial  action  of  serum,  as  measured 
by  test-tube  reactions,  and  natural  immunity ;  this  latter,  therefore,  cannot  depend 
upon  this  property  of  the  body  fluids ;  still  it  is  important  to  keep  in  mind  that 
under  certain  conditions  these  fluids  may  display  this  destructive  power  over 
many  forms  of  bacteria.  Often  this  display  does  not  take  place  until  the  animal 
has  been  infected.  Thus  it  has  been  shown  that  the  blood  of  the  dog,  an  animal 
immune  from  anthrax,  possesses  in  vitro  no  antibacterial  power  against  the 
B.  anthracis,  until  the  animal  has  been  inoculated  with  this  bacillus ;  and  Pfeiffer 
and  Issaeff  have  shown  that  the  injection  of  guinea-pig's  serum  into  a  guinea-pig 


7 6  GENERAL  PATHOLOGY  OF  DLSEASE. 

raises  the  bactericidal  power  of  the  latter.  These  antibacterial  substances,  there- 
fore, can  (a)  partly  exist  in  the  serum,  and  (6)  partly  are  poured  into  it  as  the 
result  of  some  reaction,  and  probably  have  a  common  origin,  being  natural  products 
of  the  leucocytes,  as  a  direct  correlation  has  been  clearly  demonstrated  between 
the  number  of  white  blood  corpuscles  present  in  blood  serum  or  exudation,  and 
this  bactericidal  power.  In  inflammation,  leucocytic  infiltration  occurs  in  situ, 
and  there  is  generally  a  copious  hsemic  leucocytosis ;  hence  the  amount  of  bacteri- 
cidal substances  both  in  situ  and  in  the  circulation  must  be  considerably  increased, 
and  in  the  susceptible  animal  the  infecting  bacteria  are  promptly  destroyed,  if 
they  are  so  balanced  against  the  tissues  as  to  irritate  them  to  reparative  inflam- 
mation ;  leucocytes  appear  to  supply  additional  antibacterial  substances  ;  the  latter 
destroy  the  micro-organisms,  and  their  intracellular  poisons  attract  still  more  leuco- 
cytes by  a  process  of  chemiotaxis.  Phagocytosis  will  also  occur,  as  it  does  in 
every  form  of  reparative  inflammation,  but  only  when  the  fight  is  practically  over. 
Useful  it  is,  and  no  doubt  it  assists  in  the  struggle,  but  it  is  not  the  cause  of 
immunity  any  more  than  it  is  the  ruling  principle  of  inflammation.  It  is  an 
observation  which  can  be  easily  made,  that  bacteria  can  be  inhibited  and  destroyed 
en  masse  without  the  intervention  of  phagocytosis.  Finally,  it  must  be  mentioned 
that  antitoxic  substances  are  found  in  and  given  out  by  the  leucocytes,  so  that,  so 
far  as  these  cells  are  concerned,  the  foundation  of  natural  immunity  is  fairly  firm ; 
it  must  be  understood,  however,  that  exclusive  importance  must  not  be  attached 
to  this  one  class  of  cells ;  there  may  be  other  cells,  other  organs  in  which  bacteri- 
cidal or  antitoxic  substances  are  secreted  or  produced — the  liver,  for  instance. 
The  naturally  immune  body  reacts  to  a  bacterial  invasion,  just  as  it  would  to  any 
form  of  irritation,  by  means  of  its  natural  defensive  mechanisms. 

Attempts  have  been  made  by  several  observers  to  separate  the  antibacterial 
substances  in  the  serum.  Buchner  found  that  heating  to  55-60°  C.  for  a  half  to  one 
hour,  and  the  addition  of  water,  destroy  them,  that  the  addition  of  sodium  sulphate 
increases  their  action  and  resistance,  and  that  40  per  cent,  sodium  sulphate  precipi- 
tates them.  He  gave  them  the  name  of  atoxines,  and  classifies  them  among  the 
albuminoid  substances.  Others  have  shown  that  nuclein  and  nucleinic  acid  have 
markedly  bactericidal  and  immunising  properties.  All  agree  that  the  leucocytes 
are  one  of  the  main  sources  of  these  substances,  whether  set  free  by  secretion 
or  by  the  death  of  the  corpuscles  (Metchnikoff  s  phagolysis). 

Acquired  immunity. — (a)  Non-specific  immunity. — Non-specific  acquired 
immunity  may  be  explained  by  assuming  that  the  substances  used  for  immunisa- 
tion react  on  the  tissues,  inciting  them  to  inflammation,  which  is  accompanied  by 
a  local  infiltration  of  leucocytes,  and  a  general  hsemic  leucocytosis.  This  results  in 
a  production  of  general  antibacterial  and  antitoxic  substances,  which  evidently  will 
be  present  in  greater  abundance  at  the  site  of  the  inflammation  than  elsewhere ; 
hence  the  non-specific  immunity  is  always  most  evident  locally,  i.e.  where  the 
immunising  injection  was  administered.  This  is  readily  understood  after  what 
has  gone  before,  but  it  must  not  be  forgotten  that  other  factors  besides  the  leuco- 
cytes may  play  a  part.  Moreover,  there  are  various  forms  of  leucocytes,  and 
therefore  various  forms  of  leucocytosis ;  and  it  appears  that  from  the  different 
types  of  leucocytes,  different  substances  are  obtainable :  thus  the  atoxines  of 
Buchner  are  traced  to  the  granular  leucocytes,  while  from  the  lymphocytes  anti- 
toxic substances  (nucleo-histon)  have  been  prepared.  A  non-specific  artificial 
immunity  is  of  short  duration,  because  the  increase  of  the  general  or  normal  anti- 
bacterial and  antitoxic  substances  is  temporary,  and  the  latter  are  soon  used  up 
and  eventually  excreted ;  they  have  been  found  in  the  urine  of  animals  during 
and  after  recovery  from  artificially  produced  fever. 

(b)  Specific  active  immunity. — If  an  animal  be  immunised  by  means  of  sub- 
cutaneous injections  with  a  toxine — (a)  its  resistance  both  against  other  toxines 
and  bacteria  as  a  whole  is  slightly,  mainly  locally,  and  temporarily  raised;  (b)  its 
specific  resistance  against  the  bacterium  which  yielded  the  original  toxine  is  con- 
siderably, uniformly  all  over  the  body,  and  more  enduringly  raised ;  and  (c)  its 


SPECIFIC  ACTIVE  IMMUNITY.  77 

specific  resistance  against  the  toxine  itself  is  raised  still  more,  and  equally, 
uniformly,  and  enduringly.  This  may  be  explained  by  assuming — (1)  that  the 
injections,  by  producing  repeated  inflammatory  reactions,  cause  an  increase  of  the 
general  or  normal  antibacterial  and  antitoxic  substance,  more  marked  locally  than 
elsewhere;  (2)  that  the  toxine,  repeatedly  and  in  steadily  growing  doses  injected 
into  the  tissues,  produces  chemical  changes  in  them  of  a  more  lasting  nature,  and 
uniformly  distributed  over  the  body  ;  these  result  in  the  formation  of  specific  anti- 
bacterial and  antitoxic  substances,  the  latter  being  present  in  larger  quantities. 
The  slight  non-specific  general  immunity  soon  disappears,  and  with  it  the  amount 
of  general  antibacterial  and  antitoxic  substances  is  brought  to  its  normal  level ;  but 
the  specific  immunity  from  infection  and  intoxication  continues,  and  during  the 
greater  period  of  its  continuance  the  blood  or  serum  displays  both  specific  anti- 
bacterial and  antitoxic  powers.  Eventually  both  may  be  lost  while  the  immunity 
from  infection  and  intoxication  still  persists.  These  specific  substances  are  newly 
acquired,  and  are  not  evolved  from  those  normally  existing,  because  the  latter, 
except  immediately  after  an  immunising  injection,  do  not  alter  in  the  least.  How 
they  are  acquired  and  whence  they  come  is  not  known.  They  are  essentially 
different  from  the  normal  substances  (Buchner's  atoxines),  for  they  bear  heating 
at  60°  ;  and  when  injected  into  a  normal  animal,  they  produce  a  specific  passive 
immunity,  while  with  normal  serum  only  a  very  slight  temporary  immunity  can 
be  produced.  The  specific  antibacterial  and  antitoxic  powers  are  gradually 
developed  and  distributed.  Centanni  found  that  at  the  end  of  the  antirabic 
vaccination  the  blood  displays  some  immunising  action,  while  in  the  spinal  cord 
this  is  absent ;  after  two  weeks,  blood  and  cord  possess  it  to  the  same  degree ;  and 
after  a  further  four  weeks  the  cord  alone  is  active,  while  in  the  liver,  kidneys, 
and  spleen  no  immunising  substances  are  found  at  any  period.  From  all  this  it 
follows  that  the  specific  antibacterial  and  antitoxic  substances  are  products  of 
certain  unknown  reactions  in  the  living  body,  and  are  not  merely  altered  toxines. 
As  Ehrlich  pointed  out,  they  are  not  a  new  creation  of  strange  atomic  groups,  but 
a  reconstruction  of  existing  ones,  comparable  to  a  process  of  fermentation.  Certain 
affinities  exist  between  toxine  and  certain  cell  constituents ;  thus  tetano-toxine  is 
taken  up  and  held  with  avidity  by  the  motor  ganglion  cells,  so  that  the  latter 
must  contain  atom  groups  possessing  a  special  and  specific  affinity  for  this  toxine. 
A  minimal  quantity  of  poison,  at  the  commencement  of  immunisation,  at  once 
combines  with  the  atom  group,  which  has  an  affinity  for  it ;  and  the  cell  immedi- 
ately, according  to  the  law  of  repair,  forms  a  new  group ;  as  the  immunisation  is 
continued,  more  and  more  such  groups  are  formed,  more  than  are  necessary,  these 
latter  eventually  passing  into  the  circulation.  Hence,  according  to  Ehrlich,  these 
specific  antibacterial  and  antitoxic  bodies  are  merely  a  collection  in  the  blood  of 
such  atom  groups  of  the  cell  protoplasm  as  have  a  maximal  specific  affinity  for  the 
toxine.  This  explains  why  the  process  of  immunisation  must  be  continued  to 
obtain  an  immunising  blood,  and  why  the  immunising  power  of  the  blood  ceases 
before  the  immunity,  and  also  why  it  is  that  in  hydrophobia  the  cord  retains  its 
immunising  power  longer  than  does  the  blood.  The  delicate  chemical  relations  and 
affinities  involved  become  evident,  if  it  be  remembered  that  no  crystallised  poison, 
no  poisonous  alkaloid,  glucoside,  or  other  well-defined  substance  is  capable  of  pro- 
ducing antitoxines.  Enzymes  and  toxines  alone  can  do  this.  These  substances  can 
only  act  as  poisons  if  they  find  in  certain  cells  atom  groups  capable  of  binding 
certain  noxious  atom  groups  of  these  substances ;  this  explains  the  long  incuba- 
tion period  characteristic  of  some  intoxications  with  these  substances :  it  takes 
some  time  before  the  toxic  atomic  group  becomes  anchored. 

*  (c)  Specific  passive  immunity. — Why  or  how  is  the  serum  of  a  highly 
immunised  animal  capable  of  conferring  upon  another  animal  of  the  same  or  a 
different  species  an  immunity  against  the  bacterium  or  its  products,  which  were  used 
for  the  immunisation  of  the  animal  supplying  the  serum  1  It  may  be  recalled — 
(1)  that  the  serum  obtained  from  an  animal  immunised  by  increasing  doses  of 
toxine  is  both  a  strongly  antitoxic  and  an  almost  equally  strongly  antibacterial 


78  GENERAL  PATHOLOGY  OF  DISEASE. 

immunising  agent,  but  (2)  that  the  serum  obtained  from  an  animal  immunised  by 
increasing  doses  of  bacteria  is  a  highly  antibacterial  but  much  less  antitoxic  agent, 
its  antitoxic  power  varying  mainly  with  the  toxogenetic  properties  of  the  bacteria 
used ;  and  (3)  that  the  serum  of  the  immunised  animal,  like  that  of  any  normal 
animal,  is  capable  of  producing  a  temporary,  more  or  less  local  and  slight  non- 
specific antitoxic  and  antibacterial  immunity. 

The  process  of  immunisation,  whether  toxines  or  bacteria  be  used,  is  a  chemical 
one,  but  the  chemical  substances  not  being  identical,  the  changes  produced  in  the 
serum  differ.  In  the  one  case  (toxine  immunisation)  a  solution  which  contains 
(a)  large  quantities  of  the  excreted  or  secreted  poisons,  and  (b)  also  large  quanti- 
ties of  bacterial  cell  substances,  is  used ;  while,  in  the  other  case,  a  solution  which 
contains  (a)  mainly  bacterial  bodies,  and  (b)  no  more  toxine  than  happens  to  be  in 
the  bacterial  cells.  Naturally  the  injected  bacteria  will  produce  a  little  more 
toxine,  and  the  effect  of  this  must  be  added.  The  serum  of  an  animal  immunised 
with  bacteria,  therefore,  possesses  substances  capable  of  counteracting  in  the  body 
the  intracellular  poisons,  and  deprives  the  bacteria  of  one  of  their  formidable 
weapons ;  and  if  their  other  weapon,  the  intracellular  poison,  is  blunted,  or  is 
too  weak  or  insignificant  in  amount,  the  animal  survives,  because  its  tissues 
by  an  inflammatory  reaction  can  cope  with  the  harmless  foreign  bodies;  but 
if  this  latter  weapon  is  powerful  enough,  the  animal  not  being  protected  against 
it  will  surely  die.  Hence  it  follows  that  to  give  a  useful  immunising  serum, 
an  animal  must  be  immunised  with  the  extracellular  poisons  which  contain 
both  toxine  and  bacterial  substances ;  then  the  tissues  are  guarded  against  both 
weapons. 

Reactions  of  immunising  serum. — Taking  the  pre-eminently  antitoxic 
serum  first,  it  has  been  shown  that  it  is  capable  of  rendering  a  poison  harm- 
less, either  when  mixed  with  it  in  the  test-tube  or  when  injected  before  or  after 
it ;  a  certain  amount  of  serum,  will  neutralise  a  certain  dose  of  toxine  with  almost 
mathematical  accuracy,  and  no  more ;  if  the  serum  be  injected  first  and  the  poison 
later,  smaller  doses  suffice  than  if  the  two  are  injected  simultaneously  ;  and,  again, 
if  the  two  are  injected  in  the  same  situation,  smaller  quantities  of  serum  are 
required  than  if  they  are  injected  in  different  situations;  the  serum  is  fairly 
resistant  to  heat  and  putrefaction ;  boiling,  however,  destroys  the  antitoxic  power. 
If  proper  quantities  of  antitoxine  and  a  toxine  resistant  to  boiling  heat  (snake 
venom)  be  mixed,  and  subjected  to  a  temperature  of  100°  C,  the  antitoxine  is 
destroyed,  but  the  toxine  remains  intact.  Then,  too,  it  requires  different  quantities 
of  antitoxine  for  animals  of  different  susceptibility  to  counteract  in  the  body  the 
same  amount  of  toxine;  it  is  evident,  therefore,  that  the  power  of  antitoxine  does 
not  depend  on  a  chemical  union  which  might  be  effected  in  the  test-tube  by 
adding  one  to  the  other,  but  on  something  else. 

The  pre-eminently  antibacterial  serum  is  effective  when  serum  and  culture 
are  mixed  together,  or  one  is  injected  before  the  other,  but  that  the  quantity 
of  serum,  just  as  explained  for  the  antitoxic  serum,  varies  according  to  the 
method  and  site  of  inoculation  used ;  heating  for  twenty  hours  at  60°  C.  does 
no  material  damage  to  the  activity  of  the  serum  in  the  animal  body,  although 
boiling  destroys  it  at  once  ;  putrefaction  and  weak  antiseptics  (J  per  cent,  carbolic) 
have  little  effect. 

A  serum  possessing  marked  bactericidal  powers  shows  certain  interest- 
ing reactions  with  bacterial  cultures  in  the  test-tube  or  on  the  microscopic 
slide.  Thus  the  addition  of  a  serum  obtained  from  an  animal  immunised  with 
cholera  cultures  to  a  suspension  of  cholera  vibrios  (1)  renders  them  motion- 
less, (2)  causes  them  to  collect  in  thick  clumps  or  clusters,  and  (3)  finally 
converts  them  into  granular  bodies  or  masses.  The  serum  exerts  a  paralys- 
ing or  agglutinating  action  upon  the  vibrios.  The  same  phenomenon  has  been 
demonstrated  for  numerous  (mostly  motile)  organisms  and  their  respective 
specific  immunising  sera.  It  must  be  mentioned,  however,  that  normal  serum 
may  display  the  same  power,  but  only  when  used  in  high  degrees  of  concentration, 


SEE  UM  RE  A  CTION.  7  9 

while  of  a  highly  active  immunising  serum  only,  almost  immeasurably  small 
quantities  may  be  necessary.  The  processes  underlying  these  curious  phenomena 
are  as  yet  not  satisfactorily  explained,  and  it  must  suffice  to  state  that  the  agglu- 
tinating action  and  the  immunising  do  not  necessarily  go  hand  in  hand ;  indeed, 
on  heating  the  serum  to  60°  C,  which  destroys  the  agglutinating  action,  the 
immunising  power  is  not  interfered  with. 

Further,  such  a  serum  often  exhibits  considerable  bactericidal  powers  in  the  test- 
tube,  which,  like  the  less  considerable  bactericidal  power  of  normal  serum,  is 
destroyed  by  heating  it  to  60°  C,  a  temperature  which  does  not  materially 
interfere  with  the  immunising  power.  Hence  the  latter  cannot  depend  merely  on 
this  direct  antiseptic  activity.  This  is  further  proved  by  the  fact  that  the  normal 
serum  of  many  animals  possesses  strongly  bactericidal  powers  upon  organisms 
Avhich  are  often  very  virulent  to  such  animals,  and  yet  devoid  of  all  but  the  most 
primitive  immunising  power.  Again,  dilutions  of  immunising  serum  with  broth, 
which  have  lost  bactericidal  power  in  the  test-tube,  are  still  highly  active  in  the 
animal  body.  Hence  there  can  be  no  doubt  that  the  immunising  effect  is  to  be 
explained  by  something  essentially  different  from  the  agglutinating  and 
bactericidal  action. 

It  follows  that  the  effect  of  the  antitoxine  and  antibacterial  substances  depend 
on  reactions  which  occur  in  the  body ;  outside  the  body  the  antagonistic 
substances  are  inactive,  because  they  do  not  meet  the  necessary  chemical 
conditions  to  bring  them  into  play. 

1.  When  a  serum  obtained  from  an  animal  immunised  with  certain  bacteria  is 
mixed  with  the  same  cultures,  Pfeiffer  showed  that  the  organisms,  if  motile,  be- 
come paralysed  and  agglutinated,  granular,  and  eventually  disappear  altogether,  even 
after  the  serum  has  been  heated  and  its  natural  bactericidal  power  destroyed. 
This  takes  place  often  with  astounding  rapidity,  in  the  early  stages  of  the  process, 
without  the  intervention  of  the  phagocytic  cells.  It  must  be  assumed  that  the 
tissues  cause  the  splitting  off  from  the  serum  of  the  substances  necessary  to  bring 
about  directly  or  indirectly  the  destruction  of  the  bacteria.  Probably  this  process 
is  an  indirect  one,  in  the  sense  that  the  substances  split  off  combine  with  the  toxic 
bacterial  substances,  forming  atoxic  compounds,  the  bacteria  themselves  thus 
becoming  for  the  time  being  harmless  and  a  prey  to  the  normal  defensive 
mechanisms,  which  too  are  considerably  increased  by  the  accompanying  inflammatory 
reaction.  If  the  tissues  fail  to  produce  this  splitting  off,  paralysed  by  an  excessive 
dose  suddenly  administered,  or  by  the  strong  toxines  contained  in  the  dose,  or  by 
previous  interference,  the  bacteria  proliferate,  produce  their  toxines,  and  destroy 
the  animal.  As  Pfeiffer  puts  it,  the  immunising  substances  are  present  in  the 
specific  serum  as  an  inactive  modification ;  but,  under  the  necessary  chemical 
stimulus,  this  is  converted  into  an  active  form ;  these  substances,  indeed,  may  be 
compared  to  inactive  zymogen  granules,  which,  upon  the  necessary  excitation, 
become  converted  into  an  enzyme,  and  the  latter  meeting  with  chemical 
substances  of  certain  similar  stereo-chemical  substances,  elaborates  fresh  com- 
pounds, chemically  and  physiologically  different  from  both  the  enzyme  and 
the  medium  upon  which  it  acts.  Similarly,  the  inactive  modification  of 
the  immunising  substance  becomes  converted  upon  the  adequate  tissue  stimula- 
tion into  the  active  modification,  and  this  meeting  in  the  bacterial  substances 
an  atom  group  of  similar  configuration,  binds  them  and  forms  new  atoxic 
bodies.  This  action  having  taken  place,  the  bacteria,  as  explained,  are  destroyed 
by  ordinary  defensive  mechanisms,  or  perhaps  also  as  the  yeast  cell  by  the 
products  of  fermentation.  Here,  as  in  fermentation,  the  concentration  of  the 
fluid  is  of  importance. 

2.  The  action  of  the  antitoxic  serum  in  the  body  may  be  explained  in  the 
same  manner,  and  this  is  the  explanation  to  which  Ehrlich  inclines  after  a 
prolonged  study  of  the  antitoxines.  It  is  not  known  how  the  tissues  liberate  the 
active  antitoxic  substances,  but  once  free,  their  effect  appears  to  depend  on  their 
power  of  combining  with  the  poison  molecule.     There  must  be  atom  groups  of 


8o  GENERAL  PATHOLOGY  OF  DISEASE. 

certain  configuration  in  the  toxine,  possessing  a  maximal  affinity  for  similar  atom 
groups  in  the  antitoxine,  the  two  fitting  one  another,  in  Fischer's  words,  like  lock 
and  key.  It  has  heen  seen  that  the  specificity  of  immunising  serum  is  not 
absolute.  Thus  the  robin  antitoxine  acts  as  powerfully  against  robin  as  ricin 
antitoxine.  This  apparently  exceptional  fact  may  be  understood,  if  it  be  assumed 
that  although  robin  and  ricin  are  different  substances,  nevertheless  the  con- 
figuration of  some  of  their  atom  groups  is  so  similar,  or  even  identical,  that 
they  must  produce  during  immunisation  an  antitoxine  capable  of  action 
upon  either  substance.  The  production  of  immunising  substances,  therefore, 
shows  many  analogies  to  fermentation;  the  toxines  resemble  enzymes  to  begin 
Avith,  and  the  action  of  these  substances  presents  equally  strong  resemblances  to 
fermentation. 

Inherited  immunity. — There  is  no  doubt  that  an  active  immunity, 
whether  from  infection  or  intoxication,  specifically  acquired,  is  transmitted  to  off- 
spring. If  the  immunisation  of  the  mother  be  begun  after  impregnation,  and  con- 
tinued during  gestation,  the  offspring  will  be  immune  ;  and,  furtner,  the  immunity, 
so  far  as  unequivocal  experiments  show,  is  only  transmitted  through  the  mother  by 
the  blood,  and  not  through  the  father  ;  it  is  correlated  to  the  maternal  immunity 
and  varies  directly  with  it,  whatever  the  condition  of  the  father ;  and,  as  proved  by 
Ehrlich  and  others,  it  is  almost  always  passive ;  the  immunising  substances  in  the 
maternal  blood  are,  so  to  speak,  pumped  or  passed  into  the  foetal  tissue  ;  the  toxine 
itself  seldom  passes  the  placenta,  only  the  immunising  substances.  Like  every 
passive  immunity,  the  inherited  protection  is  transient,  and  the  young  soon  lose  it 
after  they  cease  from  suckling.  Immunising  substances  have  also  been  found  in 
the  eggs  of  hens  inoculated  against  diphtheria  or  chicken  cholera,  which  is  not 
surprising,  because,  after  immunisation,  protective  substances  are  found  in  the 
blood  and  in  many  tissues.  Therefore,  in  the  case  of  birds  also,  it  is  evidently  as 
a  rule  a  transmitted  passive  immunity.  An  active  immunisation  of  the  foetus  is 
of  course  possible,  but  it  is  rare  and  probably  occurs  only  with  bacterial 
immunisation.  It  may  be  assumed  that  in  special  cases  bacteria  pass  through  the 
placenta  barrier  and  into  the  foetus,  whose  tissues  eventually  triumph,  leaving  an 
active  immunity  behind.  This  is  evidently  not  an  inheritance  of  an  acquired 
character,  but  merely  a  process  of  intra-uterine  immunisation. 

This  may  afford  an  explanation  of  Colles'  law,  namely,  that  the  non-infected 
'mother  of  a  syphilitic  child  becomes  immune  :  this  is  passive  immunisation  of  the 
mother  through  the  foetus.  "With  the  sperma,  and  not  in  the  sperma,  the 
syphilitic  virus  is  transmitted  to  the  ovum  or  embryo,  the  latter  becomes  infected 
and  immunises  the  mother,"  because  an  antitoxine  is  formed  in  the  foetus  and 
is  taken  up  by  the  maternal  blood. 

There  is  a  further  factor  which  must  not  be  lost  sight  of,  namely,  that  since 
the  milk  of  immunised  mothers  contains  immunising  substances,  and  since,  as  has 
been  experimentally  shown,  those,  at  least  for  certain  infections  and  intoxications, 
can  produce  a  passive  specific  immunity  when  administered  per  os,  the  milk  is 
the  main  vehicle  which  conveys  the  passive  immunity  to  the  suckling  child  from 
the  mother.  The  child  is  born  possessing  a  passive  immunity,  handed  over  to  it 
in  utero  from  the  maternal  blood ;  after  birth  this  passive  immunity  is  kept  up 
and  even  raised  through  continued  suckling.  This  accumulated  suckling 
immunity  is  of  somewhat  longer  duration  than  the  ordinary  intra-uterine  immunity, 
because  the  quantity  of  protective  substances  consumed  with  the  milk  is 
considerably  greater.  In  studying  inherited  immunity,  two  important  factors 
have  to  be  kept  in  view — (a)  the  placental,  and  (b)  the  mammary  passive 
immunisation.  With  regard  to  inherited  toxine  immunisation,  these  points 
must  be  regarded  as  practically  settled  by  Ehrlich's  careful  researches ;  for  the 
hereditary  transmission  of  bacterial  immunisation  they  probably  apply  with  equal 
force;  the  experimental  proof,  however,  is  as  yet  incomplete.  There  is  certainly 
no  evidence  that  the  immunity  acquired  in  utero  is  an  inheritance  of  an  acquired 
character. 


SERUM  THERAPEUTICS. 


Seeum  Theeapeutics. 


It  was  early  pointed  out  that  the  serum  of  artificially  and  actively  im- 
munised animals  is  effective,  even  when  used  after  the  process  of  infection 
or  intoxication  has  already  begun,  and  then  that  the  curative  power  of  such 
serum  is  considerable,  and  that  if  the  treatment  be  not  begun  too  late,  or 
the  amount  of  toxine  or  bacteria  be  not  excessive,  the  animal  may  be 
saved. 

Action  of  curative  serum. — It  has  been  seen  that  active  toxine 
immunisation  produces  a  serum  possessing  both  antitoxic  and  antibacterial 
properties,  while  an  active  bacterial  immunisation  produces  a  serum  pos- 
sessing mainly  antibacterial  and  only  slightly  antitoxic  properties.  If, 
therefore,  the  object  be  to  cure  a  bacterial  disease  where  intoxication  plays 
the  chief  part,  e.g.  diphtheria  and  tetanus,  a  serum  possessing  strongly 
antitoxic  power  must  be  used.  If,  on  the  other  hand,  the  disease  is  pro- 
duced by  bacteria  which  in  the  animal  body  display  a  comparatively 
feeble  toxic  action,  e.g.  streptococcal  and  pneumococcal  infections,  a  serum 
possessing  antibacterial  powers  must  be  utilised.  As  yet  there  are  no 
means  existing  of  obtaining  the  active  extracellular  poisons  of  certain 
pathogenetic  bacteria,  such  as  the  typhoid  bacillus  or  the  vibrio  of  cholera, 
and  it  has  been  impossible  to  find  sera  possessing  more  than  an  anti- 
bacterial action.  With  such  sera,  infections  with  several  times  the  lethal 
dose  of  the  bacterial  cultures  may  be  cured,  but  at  present  the  fight 
against  the  toxines,  elaborated  by  these  organisms,  has  practically  been  a 
failure. 

Diphtheria  and  tetanus  are  essentially  intoxicative  lesions.  In  cholera 
and  typhoid  fever  the  toxaemia  is  also  marked,  so  that  in  these  diseases 
an  antitoxic  serum,  which  moreover  also  always  contains  highly  anti- 
bacterial substances,  is  required.  On  the  other  hand,  pyogenetic  lesions 
are  less  distinguished  by  their  toxic  effects ;  hence  an  antibacterial  serum 
may  prove  efficacious. 

Experiments  on  animals  with  the  poisons  of  tetanus,  diphtheria,  ricin, 
etc.,  have  shown  that  there  is  a  quantitative  relation  between  the  toxine 
and  the  antitoxine ;  for  each  species  of  animal  a  certain  dose  of  toxine  is 
neutralised  in  vitro  by  a  certain  dose  of  toxine  and  antitoxine,  and  no  less. 
This  mixture,  injected  into  the  animal,  does  no  harm.  If,  however,  after 
the  injection  of  toxine,  the  antitoxine  treatment  is  commenced,  only  when 
symptoms  of  toxaemia  have  appeared,  it  is  found — (1)  that  much  larger 
doses  than  those  previously  calculated  are  required ;  and  (2)  that,  after  a 
certain  period  has  elapsed,  no  amount  of  antitoxine  will  save  the  animal. 

It  must  be  clearly  understood  that  the  curative  effect  of  antitoxine  is 
much  more  difficult  to  obtain  than  the  protective  action,  and  that,  there- 
fore, when  disease  has  begun,  much  more  energetic  treatment  is  necessary. 
The  curative  action  of  the  serum  depends  upon  the  fact  that  the  antitoxic 
substances  are  able  to  tear  away  the  toxine  molecules  from  the  protoplasmic 
atom  groups  to  which  they  have  already  become  anchored.  The  immunis- 
ing effect  depends  upon  supplying  the  body  with  so  much  antitoxic  sub- 
stance as  is  (with  its  greater  affinity  for  toxine)  necessary  to  hind  the  toxine 
molecules,  so  as  to  prevent  them  from  finding  their  affinities  in  the  tissues 
of  the  body.  It  is  clear  that  when  the  toxine  has  already  entered  into  loose 
combination  in  the  body,  it  must  require  a  large  excess  of  antitoxine,  first 
to  tear  it  away,  and  then  to  bind  it  firmly.  If  the  combination  between 
vol.  i. — 6 


S  2  GENERAL  PA  THOL  OGY  OF  DISEA SE. 

the  toxine  and  the  tissues  becomes  firmer,  more  and  more  antitoxine  is 
required,  and  a  time  must  come  when  the  toxine  is  so  firmly  anchored 
that  it  can  no  longer  be  dislodged,  and  the  antitoxine  attracts  it  in 
vain.  Donitz  demonstrated  that  the  tetanus  poison  is  fixed  by  the 
tissues  from  the  moment  it  enters  the  blood,  and  that,  after  a  copious 
administration  of  poison,  a  lethal  dose  has  entered  into  combination  in  from 
four  to  eight  minutes.  The  latter  may,  however,  still  be  drawn  away  from 
the  tissues  by  using  ten  to  four  hundred  times  as  much  antitoxine  as  is 
required  for  neutralisation  in  the  test-tube.  The  antitoxic  serum  is 
therefore  a  true  remedy,  because  it  can  remove  the  toxine  even  when  it  has 
already  entered  into  fatal  combination.  Antitoxine,  then,  is  not  merely 
an  immunising  agent,  and  when  it  is  used  as  a  curative  drug  its  effect 
does  not  depend  merely  on  the  result  of  a  race  between  intoxication  and 
immunity.  Here  the  problem  is  probably  a  chemical  one,  analogous  in 
many  respects  to  fermentation. 

Antitoxine  does  not  directly  destroy  toxine  in  the  test-tube.  There  is  no 
question  of  direct  action.  If  a  mixture  be  made  of  pyocyaneus  toxine  and  pyo- 
cyaneus  antitoxine,  or  of  snake  poison  and  antivenin,  in  such  proportion  that  the 
mixture  is  perfectly  harmless,  heating  destroys  the  antitoxine,  but  not  the  toxine. 
It  is  in  the  living  body,  then,  that  the  toxine  and  antitoxine  are  brought  together ; 
and,  according  to  Ehrlich,  antitoxine  is  an  antidote  which,  physiologically  and 
chemically,  is  an  indifferent  substance,  which  neither  destroys  nor  precipitates 
the  poison,  and  yet  is  capable  of  rendering  large  quantities  of  poison  harmless  to 
the  living  organism.  Roux  and  Biichner  believe  that,  since  in  mixtures  of  toxine 
and  antitoxine,  which  are  physiologically  neutral,  both  components  are  present 
unaltered,  the  antitoxine  has  an  indirect  action,  stimulating  and  altering  the  cells, 
they  say,  so  as  to  render  them  immune  against  the  toxine.  This  view  is,  however, 
hardly  tenable.  Ricin  causes  defibrinated  blood  to  coagulate,  and  cobra  poison 
prevents  blood  from  coagulating ;  but  antiricin  and  antivenomous  serum  neutral- 
ise respectively  the  action  of  these  toxines  in  the-test  tube,  if  quantities  are  used 
which  also  exactly  neutralise  each  other  in  the  animal  body.  Coagulation,  as 
studied  in  the  test-tube,  is  not  a  vital  phenomenon ;  hence  these  experiments 
show  that  the  action  of  the  antitoxines  cannot  depend  on  cellular  immunisation, 
but  that  toxine  and  antitoxine  react  upon  each  other  directly  and  chemically. 
Further,  Ehrlich  has  shown  that  this  union  of  toxine  and  antitoxine  in  the  test- 
tube  is  quicker  in  concentrated  than  in  dilute  solutions,  is  accelerated  by  warmth 
and  delayed  by  cold,  the  union  becoming  firmer  the  more  concentrated  the  toxine 
and  antitoxine,  and  the  longer  they  have  reacted  upon  each  other.  Analogous 
examples  occur  in  pure  chemistry,  especially  in  the  formation  of  double  salts. 

Specificity  of  antitoxine. — If  toxines  are  specifically  different, 
their  antitoxines  are  also  specific  in  their  action.  Hence  a  diphtheria 
antitoxine  is  of  no  avail  in  tetanus  or  snake  poisoning.  The  specificity  of 
antitoxine  is  based  on  a  firm  experimental  foundation.  Yet  it  is  found  that 
an  anticobra  serum  will  act  against  all  snake  venoms,  and  even  against 
scorpion  poison,  and  that  antirobin  serum  will  act  against  ricin  as  well  as 
against  robin.  An  explanation  of  this  is  that — (a)  all  snake  venoms  are 
closely  allied  to  one  another,  daboia  poison  forming  perhaps  the  only  excep- 
tion ;  and  (b)  scorpion  poison  and  robin  may,  chemically,  be  derivatives  of 
cobra  toxine  and  ricin  respectively,  each  corresponding  in  its  structure  to  a 
body  produced  by  a  shifting  of  the  atom  complex  of  snake  poison  or  ricin, 
i.e.,  to  use  Ehrlich 's  nomenclature,  they  may  be  toxoids  of  their  respective 
toxines.  It  is  easy  enough  to  manufacture  toxoids  from  toxines,  which  may 
be  quite  harmless,  and  yet  are  capable  of  producing  an  antitoxine,  and 


SER  UM  TREA  TMENT  IN  DISEASE.  8  3 

also  of  binding  the  antitoxic  substances ;  and  it  is  therefore  quite  possible 
that  many  toxines  in  nature  represent  the  toxoids  of  other  stronger  toxines. 
This  would  readily  explain  the  vicarious  immunity  which  exists  between 
intoxications. 

The  precision  with  which  the  antitoxine  picks  out  the  cells  injured  by 
the  toxine,  which  their  affinity  for  the  latter  has  attracted,  is  little  short  of 
marvellous.  In  the  motor  cells  of  the  cord,  for  instance,  are  substances 
with  a  strong  affinity  for  the  tetanus  poison.  These  bind  the  latter, 
thus  the  cells  lose  part  of  their  function,  especially  their  inhibitory 
control,  and  the  toxic  spasms  result.  Histologically,  changes  can  be 
demonstrated  in  the  cells ;  their  granulation,  which  is  brought  out  by 
Nissl's  methylene-blue  reaction,  disappears  or  fades.  If,  now,  at  the  proper 
moment,  antitoxine  be  injected,  the  cells  soon  regain  their  granulation, 
and  again  stain  normally,  although  their  restitution  is  not  complete 
until  the  signs  of  disease  have  quite  disappeared.  It  is  hardly  possible  to 
imagine  anything  more  precise  than  this  restorative  action  of  the  anti- 
toxine. These  observations  prove  clearly  the  cellular  action  of  toxine  and 
antitoxine,  and  also  that  the  latter  is  a  true  remedy.  Antibacterial  serum 
cannot  differ  in  its  action  from  that  of  antitoxine ;  the  difference  is  merely 
chemical,  i.e.  the  poison  derived  from  the  bacterial  cell  has  a  different 
chemical  configuration  and  different  affinities.  It  can  be  of  use  olny 
against  these  substances,  and  must  be  valueless  against  toxines  which  are 
altogether  diverse,  or  do  not  stand  to  them  in  the  relation  of  toxoid  to 
toxine.  By  means  of  this  serum,  bacteria  can  be  committed  to  sudden 
death.  If,  however,  the  bacteria  have  liberated  much  toxine,  the  animal 
will  die,  since  this  serum  does  not  protect  against  the  toxine.  Therefore, 
in  practice,  an  antibacterial  serum  is  of  no  avail  in  diseases  where  toxaemia 
evidently  exists.  Thus  in  man  enteric  fever  is  essentially  a  toxaemia ; 
hence  it  is  but  little  or  not  at  all  affected  by  the  anti-typhoid  serum  derived 
from  a  horse  immunised  with  cultures  of  the  typhoid  bacillus.  Success 
must  therefore  not  be  expected,  or  hope  held  out  from  methods  which 
science  points  out  are  based  on  errors  of  judgment. 

Serum  treatment. — Of  serums  for  diphtheria,  tetanus,  plague, 
typhoid,  cholera,  streptococcus  infections,  pneumonia,  snake  poison,  tuber- 
culosis, and  syphilis,  not  to  mention  rabies,  the  only  ones  that  have  a 
right  to  figure  as  of  remedial  value  are  the  diphtheria,  tetanus  and  anti- 
venomous  sera,  which  are  all  antitoxines.  Clinically,  the  diphtheria 
antitoxine  has  achieved  so  much  that  its  usefulness  can  no  longer  be 
doubted,  except  by  the  most  prejudiced  and  blinded  physician.  Tetanus 
antitoxine,  used  clinically,  has  so  far  been  accompanied  by  but  limited 
success,  and  has  failed  in  severe  cases,  and  the  anti-typhoid  and  cholera 
sera  have  been  condemned  as  useless,  for  the  reason  stated  above.  Anti- 
streptococcus  serum  has  of  late  been  extensively  used,  but  at  present  it  is 
impossible  to  speak  of  its  value  in  decided  terms.  Some  observers  claim 
that  it  has  done  good,  others  condemn  it ;  it  is  certainly  only  an  anti- 
bacterial serum,  and  therefore  cannot  do  much  good  when  the  toxaemia 
is  acute ;  and  again,  the  physician  must  always  convince  himself  that  he  is 
dealing  with  a  streptococcus  lesion,  and,  while  using  the  serum,  must  make 
the  necessary  bacteriological  investigation.  Similarly,  it  is  too  early  to 
speak  of  the  anti-pneumococcus  serum,  or  of  that  supposed  to  act  against 
plague  and  tuberculosis.  Yersin  declares  that  his  serum  has  been  of 
considerable  use  in  plague,  while  others  deny  or  doubt  this.  The  attempts 
to   prepare  an  antisyphilitic  serum  are  interesting,  but  have  as  yet  not 


84  GENERAL  PATHOLOGY  OF  DLSEASE. 

passed  beyond  the  experimental  stage.     Antivenomous  serum,  it  is  said, 
has  already  been  successfully  used  in  more  than  one  case  of  snake  bite. 

When  using  curative  serum,  the  physician  or  surgeon  should  clearly 
understand  the  dosage.  The  serum,  if  properly  and  carefully  prepared,  is 
absolutely  harmless  to  the  normal  individual.  More  will  be  said  of  its 
possible  dangers  and  complicating  effects  later.  While  dealing  with  an 
otherwise  normal  patient,  even  large  quantities  can  be  injected,  so  long  as 
this  is  done  aseptically.  The  amount  to  be  administered  must  not  be 
measured  by  drachms,  ounces,  or  cubic  centimetres,  but  by  immunising 
units.  The  physician  must  therefore  understand  the  meaning  of  this 
unit.  The  standard  employed  for  antitoxic  serum  is  that  elaborated  by 
Ehrlich,  and,  according  to  this  standard,  an  immunising  unit  is  that 
quantity  of  serum  which  is  capable  of  neutralising  one  hundred  times  the 
minimal  lethal  dose  of  the  original  standard  toxine  for  a  half -grown  guinea- 
pig.  It  is  essential  that  no  serum  be  used  unless  its  antitoxic  value  has 
been  carefully  estimated ;  and  experiments  show  that  for  clinical  use  con- 
centrated sera  are  preferable,  that  is,  sera  which  contain  a  large  number  of 
units  in  a  small  bulk.  Such  sera  can  only  be  obtained  from  animals 
which  are  not  only  strongly  immunised,  but  also  before  the  immunisation 
possessed  a  marked  susceptibility.  The  number  of  units  to  be  used  in 
each  case  varies  with  the  severity  of  the  symptoms,  and  it  is  impossible 
to  give  hard  and  fast  rules.  At  the  present  time  three  forms  of  serum  are 
clinically  employed  in  this  country,  namely,  diphtheria  antitoxine,  tetanus 
antitoxine,  and  antistreptococcus  serum ;  and  a  few  general  remarks  as  to 
dosage  may  fitly  be  made  here. 

1.  Diphtheria  antitoxine. — 1500  to  2000,  or  even  4000,  units  should  be  the 
minimum  dose,  and  this  should  be  given  early,  and,  if  necessary,  frequently 
repeated  until  all  danger  is  past.  The  number  of  units  that  may  be  given  must 
of  course  depend  on  the  supply  of  serum. 

2.  Tetanus  antitoxine. — Here  it  is  absolutely  necessary  to  use  an  extremely 
powerful  serum,  and  a  very  large  dose,  as  measured  by  units,  must  be  admini- 
stered immediately.  Intravenous  or  intracerebral  injection  holds  out  more  hope  of 
success ;  in  all  but  very  slight  cases  the  latter  method  of  administration  is  there- 
fore especially  to  be  commended.  Further  injections  may  be  given  every  twelve 
hours.  The  intracerebral  treatment  should  be  resorted  to,  unless  the  first  injec- 
tion is  made  within  thirty-six  hours  after  the  onset  of  the  spasms. 

3.  Antistreptococcus  serum. — This  being  an  antibacterial  serum,  large 
doses  should  be  used.  As  yet,  there  is  no  good  standard  for  these  antibacterial  sera; 
therefore  a  serum  which  is  known  to  be  active  in  extreme  dilutions,  when  tried  on 
laboratory  animals,  should  be  obtained,  and  of  this,  so  far  as  our  present  know- 
ledge goes,  however  strong  the  serum  proves  to  be,  20  c.c.  should  be  injected 
subcutaneously  every  twelve  hours,  until  improvement  sets  in. 

In  every  case  where  a  serum  is  used,  the  ordinary  rules  of  treatment  must 
not  be  lost  sight  of ;  the  serum  is  an  adjunct,  but  not  a  charm.  No  local  anti- 
septic measure  must  be  omitted;  no  operative  measure,  such  as  tracheotomy, 
amputation,  or  incisions,  must  be  postponed;  no  generally  approved  medicinal 
treatment  neglected.  There  has  been  a  tendency  to  regard  the  antitoxic  or 
other  sera  as  omnipotent,  but  it  must  be  remembered  that  they  act  best  in  the 
normal  body,  and  when  the  poison  to  be  neutralised  is  not  present  in  excessive 
amount.  General  and  local  treatment  tend  to  bring  the  body  nearer  its  normal 
state,  and  to  reduce  the  elaboration  of  more  poison.  The  antitoxine  is  anything 
but  the  fool's  weapon  !  That,  in  making  injection,  strict  aseptic  and  antiseptic 
precautions  must  be  observed,  goes  without  saying.  The  skin  must  be  thoroughly 
washed,  and  the  syringe,  serum,  and  everything  else  used  must  be  absolutely  sterile. 


THE  RESULTS  OF  SERUM  TREATMENT.  85 

Results. — A  few  examples  of  the  results  of  serum  treatment  may  be 
given. 

Diphtheria. — The  prognosis  in  cases  of  diphtheria  treated  with  anti- 
toxine  is  far  better  than  at  any  time  previous  to  its  introduction  as  a  method 
of  treatment,  especially  in  dangerous  forms  of  the  disease  (namely,  those 
under  five  years  of  age,  and  those  in  which  tracheotomy  is  required),  and  in 
the  case  of  those  in  whom  treatment  is  begun  early  in  the  disease,  and  when 
sufficiently  large  quantities  are  injected.  The  proper  administration  of 
antitoxine  reduces  the  mortality  considerably,  and  assists  the  older  methods 
of  treatment.  The  fact  that  Liebreich  and  others  object  that  the  new 
treatment  has  not  fulfilled  its  original  extensive  promise,  should  not  carry 
much  weight.  That  it  has  reduced  the  mortality  considerably,  speaks  for 
itself.  Every  case  cannot  be  cured,  for  when  vital  damage  has  been  done  the 
antitoxine  cannot  manufacture  new  tissues,  nor  can  the  diphtheria  serum  cir- 
cumvent or  cure  the  secondary  infections  which  only  too  often  destroy  life. 
Streptococcus  septicaemia  is  a  common  cause  of  death  in  diphtheria.  Unques- 
tionably there  is  no  better  form  of  treatment  in  diphtheria  than  to  combine 
the  administration  of  antitoxine  with  the  older  methods.  Welch  expresses 
himself  thus:  "The  study  of  the  results  of  the  treatment  of  over  7000 
cases  of  diphtheria  by  antitoxine  demonstrates  beyond  all  reasonable  doubt 
that  antidiphtheritic  serum  is  a  specific  curative  agent  for  diphtheria, 
surpassing  in  its  efficacy  all  other  known  methods  of  treatment  for  this 
disease.  It  is  the  duty  of  the  physician  to  use  it !  It  should  be  forcibly 
brought  home  to  those  whose  philozoic  sentiments  outweigh  sentiments 
of  true  philanthropy,  that  those  discoveries  which  have  led  to  the  saving 
of  untold  thousands  of  human  lives  have  been  gained  by  the  sacrifice  of 
lives  of  thousands  of  animals,  and  by  no  possibility  could  have  been  made 
without  experiments  upon  animals." 

Tetanus. — The  serum  treatment  has  not  materially  or  actually 
changed  the  prognosis  in  acute  and  serious  cases ;  but  in  milder  cases  it 
lessens  the  spasms,  the  pain  and  distress,  and,  it  seems,  reduces  the 
mortality,  but  to  what  extent  cannot  be  estimated  until  statistics  of  a 
larger  number  of  cases  have  been  collected.  Furthermore,  the  antitoxine 
may  pull  wp  a  case  which  is  rushing  away  into  acuteness,  and  increase  the 
chances  of  older  forms  of  treatment,  such  as  amputation,  morphine,  and 
chloral.  It  should  certainly  be  used  in  all  but  hopeless  cases.  Up  to  March 
1895,  the  mortality  of  acute  cases  of  tetanus,  in  spite  of  the  antitoxine 
treatment,  amounted  to  85*7  per  cent.;  but  in  chronic  cases  it  had  been 
reduced  to  5*7  per  cent.,  so  that  with  the  antitoxine  in  milder  cases  better 
results  are  obtained  than  with  methods  of  treatment  which  omit  the  new 
remedy ;  and  since,  to  use  Eoux's  words,  "  dans  la  pratique  on  ne  choisit 
ni  le  cas  ni  le  moment  de  l'intervention,"  it  is  clearly  a  duty  to  combine 
the  serum  treatment  with  other  recognised  therapeutic  methods. 

Streptococcus  lesions. — The  numbers  of  cases  reported  are  too  small, 
and  the  opinions  expressed  too  contradictory,  to  allow  of  a  definite  state- 
ment that  the  antistreptococcus  serum  is  a  remedy  which  it  is  the 
physician's  or  surgeon's  duty  to  use.  It  is  difficult  to  judge  statistically 
of  the  clinical  effect  of  antistreptococcus  serum,  because  in  many  cases  a 
bacteriological  examination  has  been  regarded  as  superfluous.  Some 
observers  go  so  far  as  to  maintain  that  even  during  natural  recovery  from 
streptococcus  infection,  the  serum  acquires  no  protective  substances. 
Koch  and  Petruschky  inoculated  a  patient  first  with  a  large  dose  of  anti- 
streptococcus  serum,   and   twenty-four    hours    later   with    streptococcus 


86  GENERAL  PATHOLOGY  OF  DISEASE. 

material,  and  repeated  this  with  various  sera ;  in  no  case  did  the  serum 
afford  the  slightest  preventive  action.  There  are,  however,  a  number  of 
cases  recorded  where  prompt  fall  of  temperature  and  recovery  have  followed 
so  quickly  upon  injections  of  the  serum,  that  it  is  very  difficult  to  dis- 
believe altogether  in  its  efficacy.  According  to  Mr.  E.  A.  Steele,  of  twenty- 
six  cases  of  puerperal  septicaemia,  unfortunately  not  bacteriologically 
examined,  only  ten  died;  recovery  from  infective  endocarditis  has  also 
been  recorded.  Since  the  serum  is  practically  harmless,  it  may  be  used  in 
dangerous  cases  of  streptococcus  infection  as  an  additional  aid,  though  the 
outlook  in  this  direction  is  not  very  hopeful,  since  this  serum  contains  no 
antitoxic  substances. 

It  is  to  a  certain  extent  unimportant  where  the  serum  is  injected. 
Generally  it  is  administered  subcutaneously,  and  in  that  case  the  buttock 
may  be  chosen  or  the  abdomen,  parts  on  which  the  patient  does  not  rest, 
and  in  which  the  muscles  may  be  kept  quiet.  In  some  serious  cases 
it  may  be  advisable  to  practise  intravenous  injection,  but  this  has  as  yet 
not  found  general  approval,  although  when  the  toxaemia  is  severe  it  would 
probably  be  more  efficacious  than  a  subcutaneous  administration.  Some 
observers  claim  that  in  animals  the  antitoxine  may  exert  its  action  even 
when  given  by  the  mouth.  This  is,  however,  an  uncertain  method  of 
administration,  and  the  experimental  evidence  is  by  no  means  strong 
enough  to  justify  its  recommendation  ;  furthermore,  it  would  require  very 
large  doses  to  be  of  any  value,  and  at  best  this  method  of  treatment  would 
be  costly  as  well  as  doubtful. 

The  serum  may  be  used  liquid  or  dry.  In  the  latter  case  it  must  be 
dissolved  in  a  small  bulk  of  sterile  water  (2-5  c.c),  and  strict  cleanliness 
and  antiseptic  precautions  must  be  observed;  the  water  should  never 
register  higher  than  the  body  temperature,  as  heating  destroys  the  action  of 
the  antitoxine.  The  serum  is  not  very  sensitive  to  light  and  the  ordinary 
changes  of  temperature,  and  may  be  kept  for  some  time,  though  it  usually 
loses  in  power,  especially  for  the  first  year.  A  turbid  liquid  serum  should 
never  be  employed,  because  this  generally  means  bacterial  contamination. 
The  dry  serum,  which  is  very  stable  when  dissolved,  is  always  turbid,  and 
must  not  be  filtered,  but  used  immediately  the  solution  has  been  made.  A 
bottle  of  serum  should  only  be  used  once,  i.e.  it  should  not  be  opened  and 
then  put  away  for  further  use.  As  a  matter  of  fact,  each  bottle  never 
contains  more  than  a  single  dose.  When  the  injection  has  been  made,  the 
parts  should  not  be  kneaded,  under  the  impression  that  this  will  hasten 
absorption.  If  intravenous  injection  has  been  decided  upon,  a  liquid 
serum  should  be  used  and  not  a  dry  one,  for  fear  of  embolisms.  A  syringe 
should  be  chosen  which  will  contain  the  entire  dose,  necessitating  only  a 
single  puncture ;  the  piston  must  fit  tightly,  and  on  no  account  should  air 
be  injected.  These  are  a  few  general  rules,  which  the  physician  must 
observe  unhesitatingly. 

Complications. — Among  the  alleged  ill  effects  which  have  been 
attributed  to  the  use  of  serum,  the  most  important  are  the  following : — 
Rashes,  joint  affections,  inflammation  about  the  seat  of  inoculation, 
abscesses,  albuminuria  and  nephritis,  collapse  and  sudden  death,  and 
pyrexia.  First  it  must  be  said  that  with  the  improvements  in  the 
methods  of  obtaining  and  preparing  the  antitoxine,  these  complications  are 
steadily  decreasing,  although  the  number  of  patients  treated  and  the 
amount  of  antitoxine  has  considerably  increased.  Experiments  and  ex- 
perience have  shown  that  antitoxic  serum,  as  far  as  toxic  and  constitutional 


TOXEMIA.  87 

symptoms  are  concerned,  act  exactly  like  ordinary  normal  animal  serum. 
The  rashes  which  undoubtedly  appear  are  not  due  to  the  antitoxine  con- 
tained in  the  serum,  but  are  due  probably  to  substances  in  normal  horse 
serum.  These  substances  can  be  partially  avoided  by  using  highly  con- 
centrated serum,  i.e.  one  containing  a  large  number  of  units  in  a  small 
bulk. 

Joint  affections  are  now  extremely  rare,  inflammation  and  abscesses  are 
avoidable,  and  are  not  due  to  the  antitoxine ;  albuminuria  and  nephritis 
appear  to  be  symptoms  of  the  disease  rather  than  effects  of  the  antitoxine. 
Collapse  and  sudden  deaths  have  occurred,  but  these  must  be  due  to 
some  idiosyncrasy  on  the  part  of  the  patient,  and  can  count  for  about 
as  much  as  the  rare  deaths  that  ensue  from  the  use  of  ether  or  chloroform. 
The  essential  harmlessness  of  the  serum  has  been  sufficiently  demonstrated 
by  hundreds  of  thousands  of  injections ;  and  what  little  harm  there  is  in 
serum  will  no  doubt  in  course  of  time  be  remedied  altogether,  when  pure 
antitoxine  or  serum  is  obtained  of  such  concentration  that  minute  doses 
are  sufficient  to  contain  the  required  number  of  units. 

ToXiEMIA. 

The  symptoms  and  lesions  of  infective  diseases  are  due  mainly  to 
the  toxines  manufactured  by  the  bacteria,  and  not  to  the  mechanical 
presence  of  these  bacteria.  The  diseases  associated  with  infective 
micro-organisms  are  produced  by  processes  of  intoxication.  Many  other 
lesions  and  diseases,  or  their  symptoms,  are,  however,  caused  by  poisons, 
to  which  it  is  necessary  to  devote  a  few  words. 

Nature  of  poisons. — Poisons  may  either  be  introduced  into  the 
body,  as  such,  from  without,  or  they  may  be  manufactured  in  and  by  the 
tissues  themselves,  whence  they  are  absorbed.  In  the  latter  case  they  may 
be  formed  either  during  the  ordinary  metabolic  activity  of  the  tissues,  or 
during  normal  fermentative  processes  set  up  by  the  tissue  enzymes,  or 
by  bacteria  which  must  be  regarded  as  normal  inhabitants  of  the  digestive 
tract;  or,  again,  they  may  be  the  products  of  an  abnormal  metabolism 
or  abnormal  bacterial  fermentation,  or  of  pathogenetic  bacterial  activity. 
These  poisons  may  be  classed  as  follows — 

I.  Exogenous  poisons,  e.g.  arsenic,  alkaloids,  snake  poisons,  etc. 
II.  Endogenous  poisons — 

(1)  Metabolic — (a)  Normal  metabolism  =  waste  products. 

(b)  Abnormal      metabolism  =  cachexia      strumipriva, 
uraemia,  cholasmia,  diabetic  coma,  etc. 

(2)  Tissue  fermentation  =  enzymes,  albumoses,  etc. 

(3)  Bacterial  fermentation — (a)  Normal  =  products  of  bacterial  action 

in  digestive  tract. 
(b)  Abnormal  =  intestinal  fermentations. 

(4)  Pathogenetic  bacterial  activity  =  infective  diseases. 

The  action  of  a  poison  appears  undoubtedly  to  depend  upon  chemical  affinities 
existing  between  it  and  the  tissues,  or  some  elements  of  the  tissues.  Irritants  or 
agents  which  act  directly  by  causing  immediate  death  of  the  tissues  with  which 
they  come  in  contact,  must  not  be  included  amongst  the  poisons,  but  only  those 
substances  which,  whatever  their  local  action  may  be,  have  a  distant  or  remote 
action  upon  the  blood  or  internal  organs.  This  remote  action  may  show  itself 
(a)  in  organs  whose  function  it  is  to  retain  or  excrete  the  poison,  or  (b)  in  organs 
which  are  not  possessed  of  such  function,  and  therefore  must  be  supposed  to  have 


88  GENERAL  PATHOLOGY  OF  DLSEASE. 

a  special  affinity  for  certain  poison  molecules.  This  explains  the  remarkable 
selective  action  of  certain  poisons — lead,  strychnine,  tetanus  toxine,  diph- 
theria toxine,  and  snake  poison  (all  show  great  affinity  for  the  nervous 
system),  phosphorus,  arsenic,  and  antimony  for  the  blood,  liver,  kidneys,  and 
heart.  Again,  of  the  nerve  poisons,  some  select  the  peripheral,  others  the  central 
system. 

We  may  therefore  distinguish  between  poisons  which  act  primarily — 
(1)  on  the  blood ;  (2)  on  the  heart;  (3)  on  the  nervous  system — (a)  on  the 
peripheral  nerves  (motor  or  sensory),  (&)  on  the  spinal  cord,  (c)  on  the 
medulla,  and  (d)  on  the  brain  itself ;  and  (4)  on  the  protoplasm  generally. 
These  last  are  general  poisons,  and  may  act  chemically — (1)  by  oxidation 
(phosphorus  and  arsenic) ;  (2)  by  catalysis  (chloral,  ether) ;  (3)  by  forma- 
tion of  salts  (salts  of  heavy  metals) ;  or  (4)  by  substitution  (hydrocyanic 
acid,  phenoldiamine).  There  are  also  the  special  poisons  which  select 
only  certain  elements  and  molecules,  and  do  not  act  on  the  protoplasm 
generally. 

In  the  case  of  tetanus,  it  is  evident  that  in  the  motor  cells  of  the  spinal 
cord  there  must  be  atom  groups  which  possess  a  specific  affinity  for  the 
tetano-toxine,  while  the  other  organs  of  the  body  show  no  such  predilec- 
tion. The  special  poisons  differ  as  greatly  in  their  chemical  constitution  as 
in  their  action.  Some  are  crystalline  poisons,  alkaloids,  glucosides,  and 
such  well-defined  chemical  substances,  which  cannot  produce  antitoxines ; 
others  are  the  toxines,  ferments,  and  toxalbumins,  all  of  which  have  the 
power  of  producing  antitoxines. 

The  general  effects  of  an  intoxication  in  bacterial  infections  may  now  be  con- 
sidered. The  products  of  bacterial  activity  include  not  only  the  specific  toxines, 
but  also  other  poisonous  substances,  and  at  present  it  is  impossible  to  separate  the 
two  groups.  There  is  a  tendency  on  the  part  of  those  studying  a  disease  to  fix 
the  attention  on  the  obvious  effects,  and  to  neglect  the  secondary  or  remote  and 
general  effects  ;  and  yet,  as  regards  treatment  and  convalescence,  a  thorough  under- 
standing of  the  effects  of  a  bacterial  toxaemia  is  absolutely  necessary.  In  typhoid 
fever,  for  instance,  besides  the  typical  temperature  curve,  the  intestinal  symptoms, 
the  prostration,  collapse,  and  mental  changes,  the  toxines  of  the  typhoid  bacillus  and 
its  associates  in  the  bowel  produce  anatomical  changes  beyond  those  found  in  the 
gut.  There  are  changes  in  the  liver,  kidneys,  muscles,  and  perhaps  also  in  other 
tissues,  all  of  importance ;  and  it  may  require  long  and  careful  treatment  during 
convalescence  to  restore  the  organs  to  their  normal  condition.  The  delayed 
recovery  from  a  fever  undoubtedly  depends  on  the  intensity  of  the  general  toxic 
effects,  and  a  patient  is  not  cured  until  these  have  entirely  disappeared.  Many 
bacterial  poisons,  in  doses  not  sufficient  to  cause  death,  produce  marasmus,  not 
due  to  the  specific  but  to  the  general  action  of  the  poison,  this  condition  always 
occurring  in  all  but  the  slightest  intoxications.  The  immediate  dangers  of  an 
infection  may  have  been  averted,  but  the  patient  has  still  to  be  carefully  watched 
and  nursed,  because  his  organs  and  tissues  are  left  in  an  injured  and  diseased 
condition,  from  which  in  some  cases  they  may  never  recover.  Many  sequelae  are 
due  to  these  less  characteristic  toxic  effects  ;  they  are  often  recognisable  anatomic- 
ally, as  evidence  that  although  the  poison  has  been  removed,  its  effects  persist,  and 
that  during  convalescence  there  may  be  very  grave  disease  and  lesions,  which,  if 
not  repaired,  may  become  progressive,  and  eventually  declare  themselves  as  almost 
certainly  fatal  diseases.  Flexner  lays  stress  upon  these  anatomical  changes  pro- 
duced by  intoxications  with  certain  toxines,  and  points  out  that  the  cells  of  the  liver 
and  kidneys  (most),  suprarenal  capsules  and  pancreas  (least),  are  affected ;  in  highly 
differentiated  cells,  not  all  the  parts  of  the  protoplasm  are  equally  affected  by  the 
poison.     The  necrosis,  at  least  in  the  liver,  may  be  followed  either  by  regeneration 


TOXAEMIA  AND  INTOXICATION.  89 

and  restoration  of  the  integrity  of  the  organ,  or,  in  the  place  of  the  dead  cells,  a 
new  tissue  develops,  which  leads  to  the  formation  of  a  scar,  and  in  some  cases  a 
form  of  cirrhosis  may  result.  In  diphtheria-intoxications  changes  in  the  cardiac 
muscle,  the  liver,  kidney,  and  suprarenal  capsules,  and  in  the  nerves,  may  all  be 
observed.  The  antitoxine  may  save  the  animal  from  death,  but  paralysis  often 
occurs,  because  the  degenerative  changes  had  already  gone  too  far :  the 
remedy  cannot  build  up  new  nerve  tissues.  Intestinal  lesions  are  common,  for 
frequently,  after  sublethal  doses,  animals,  while  emaciating,  develop  a  chronic 
diarrhoea,  which  persists  until  the  animal  eventually  dies.  Our  knowledge  of  the 
general  changes  produced  by  bacterial  toxaemia  is  still  imperfect,  but  so  far  as  it 
goes  it  teaches  the  practical  physician  the  important  lesson  that  the  convalescence 
requires  as  much  careful  attention,  if  not  more,  than  the  acute  stages  of  the 
infective  diseases. 

Besides  the  toxasmia  produced  by  the  absorption  of  bacterial  poisons,  there 
are  what  may  be  called  autotoxic  effects,  which  depend  upon  absorption 
of  chemical  substances  elaborated  in  and  by  the  tissues  themselves.  These 
substances  may  be  normal  metabolic  products  which  have  been  allowed  to 
accumulate,  or  they  may  be  abnormal  metabolic  products,  or  products 
which,  under  ordinary  conditions,  undergo  further  changes.  During  the 
process  of  metabolism  there  appear  a  number  of  intermediate  products, 
such  as  kreatin,  cystin,  glycosuria  acid,  oxalic  acid,  glucose,  lactic  acid, 
etc.,  which  normally,  by  oxidation  or  reduction,  by  synthesis  or  splitting, 
are  converted  into  other  bodies,  but  which  may  accumulate  in  a  diseased 
organ,  and  thence  be  taken  up  by  the  circulation.  During  the  metabolic 
processes  of  health,  both  harmless  and  noxious  substances  are  formed,  but 
the  latter  produce  no  ill  effect,  because  they  are  either  formed  in  small 
quantity,  or  enter  into  combination  with  other  bodies,  or  are  rapidly 
excreted  or  destroyed.  If,  for  some  reason  or  another,  they  appear 
in  unduly  large  quantity,  or  if  they  are  not  changed  into  harmless  com- 
pounds, or  excreted  and  destroyed,  they  enter  the  blood  stream  and  a 
toxtemia  results,  which  is  either  acute  and  momentary,  or  chronic  and 
periodical.  On  the  other  hand,  poisons  may  arise  through  pathological 
processes,  which  alter  the  normal  metabolism  in  such  a  way  that  new  and 
toxic  products  are  formed.  Eoughly,  the  following  forms  of  spontaneous 
toxaemia  may  be  distinguished : — 

Spontaneous  toxaemia,  due  to  the  retention  of  normal  or  physiological 
metabolic  products  (as  for  instance  uraemia  and  carbonic  acid  poisoning). 

Spontaneous  toxaemia,  due  to  an  over-production  of  physiological  or 
pathological  metabolic  substances  (diabetic  coma,  acetonuria,  cystinuria, 
cancerous  cachexia). 

Spontaneous  toxaemia,  due  to  removal  or  exclusion  of  an  organ 
(myxoedema,  acute  yellow  atrophy  of  the  liver,  pancreatic  diabetes, 
Addison's  disease).  The  thyroid  gland,  liver,  pancreas,  and  suprarenal 
bodies  are  assumed  to  destroy  toxic  metabolic  products,  and  if  these  glands 
are  diseased  such  products  must  accumulate. 

Spontaneous  toxaemia,  due  to  general  metabolic  disturbances  (gout, 
oxaluria,  diabetes). 

Arranging  the  toxaemias  according  to  the  organ  in  which  the  poison  is 
produced,  accumulated,  or  through  which  it  is  retained  in  the  body,  they 
may  be  due  to — 

1.  Cutaneous  lesions — Extensive  burns  and  varnishing"!  z.e.  Retention  of  sub- 

2.  Renal  disease — Uraemia,  eclampsia  .  .  .  .  \     stances   normally 

3.  Lung  disease — Carbonic  acid  poisoning     .  .  .  j      excreted. 


9o  GENERAL  PATHOLOGY  OF  DLSEASE. 

'i.e.  Impairment    of 

4.  Suprarenal  disease — Morbus  Addisonii     .          .          .  <=       ,              , 

5.  Pancreatic  disease — Some  forms  of  diabetes      .          .  r      .  '            + 

6.  Hepatic    disease — Acute     yellow    atropby,     tetany,  ,,.■'. 
enormia    .                   ......         .  ^te^te    " 

7.  Thyroid   disease — Myxcedema,    cachexia,    cretinism,  '"     £  c  ,, 
Graves's  disease  .         .         .         .         .         .         .  t>t>  iy    or      e 

normal  metabolic 
activity. 

i.e.    Abnormal    fer- 
mentations    and 
Intestinal     disease  —  Acute     and     chronic     gastro-/      impaired   absorp- 
intestinal  lesions  .  .  .  .  .  .)      tion  • — -putrefact- 

ive and  bacterial 
toxines. 

It  may  be  objected  that  the  symptoms  of  any  disease  are  due  to  intoxication, 
and  there  can  be  no  doubt  that  chemical  changes  accompany  every  organic  lesion. 
Thus,  in  heart  disease,  when  compensation  breaks  down  and  the  respiratory  activity 
is  lowered,  the  blood  is  impaired,  and  amongst  other  changes  there  must  be 
diminished  oxidation  and  diminished  combustion  of  the  waste  products.  Such 
conditions  are,  however,  not  included  under  toxaemia,  unless  they  are  accom- 
panied by  distinct  symptoms  of  intoxication. 

It  is  important  to  know  what  conditions  may  lead  to  a  toxaemia,  on  a  clear 
understanding  of  which  treatment  must  depend.  Toxaemic  conditions  can  only 
occur  when  one  or  more  of  the  paths  of  excretion  are  blocked,  if  the  activity  of 
certain  organs  has  been  impaired  or  abolished,  or  if  the  amount  and  intensity  of 
the  poison  is  too  great  for  the  normal  mechanism  to  cope  with. 

Under  normal  conditions,  metabolic  poisons  are  excreted  by  the  skin  (evidence 
derived  from  varnishing  the  skin),  kidneys,  and  intestines ;  urticarial  eruptions 
are  undoubtedly  due  to  a  reaction  of  the  skin  against  the  excreted  irritant.  To 
some  extent  the  lungs  also  eliminate  poisonous  substances,  especially  volatile 
gases  (acetone,  ammonia,  sulphuretted  hydrogen,  the  products  of  retrogressive 
changes). 

Other  organs  neutralise  or  destroy  poisons.  The  liver  has  the  power  of 
rendering  harmless — (a)  poisons  which,  after  being  introduced  into  the  in- 
testinal canal,  find  their  way  into  the  portal  circulation,  and  (b)  of  modifying 
the  toxic  metabolic  substances  which,  under  normal  conditions,  are  carried  to  it 
by  the  portal  circulation.  Speaking  generally,  the  alkaloids  lose  about  half  their 
toxic  power  in  passing  through  the  liver,  but  it  must  be  remembered  that  in  this 
matter  different  species  of  animals  vary  considerably.  It  has  been  demonstrated 
that  if  the  inferior  vena  cava  and  portal  vein  be  so  connected  as  to  divert  the  portal 
blood  into  the  vena  cava  from  the  hepatic  filter,  the  animal  dies  of  a  chronic 
toxaemia,  which  in  many  respects  resembles  the  uraemic  condition.  Here  it  must 
be  assumed  that  the  poisonous  substances  formed  during  digestion  pass  directly 
into  the  systemic  circulation,  and  that  an  autotoxaemia  results.  Hence  it  may 
be  concluded  that,  if  through  anatomical  or  physiological  disturbances  the  filtering 
action  of  the  liver  is  impaired  or  abolished,  the  poisonous  substances  of  a  normal 
or  abnormal  metabolism  readily  find  their  way  into  the  general  circulation. 

The  kidneys,  besides  excreting  poisonous  substances,  possess  toxine-destroying 
properties,  transforming  the  toxic  bodies  into  new  atoxic  compounds  by  pro- 
cesses of  oxidation  or  reduction,  synthesis  or  splitting.  It  is  possible  also  that 
the  kidneys  are  provided  with  a  so-called  internal  secretion,  the  absence  of  which 
might  lead  to  toxaemic  symptoms. 

In  the  intestinal  tract,  poisons  which  are  not  evacuated  may  be  rendered 
harmless  by  the  various  secretions,  such  as  the  bile  or  the  pancreatic  and  gastric 
juice,  or  they  may  be  acted  upon  by  the  epithelium  of  the  intestine.     It  has  been 


TREATMENT  OF  TOXEMIA.  91 

shown  that  bile  and  pancreatic  jnice  have  a  marked  action  on  so  strong  a  poison 
as  that  of  the  cobra. 

In  many  animals,  after  ablation  of  certain  organs  (thyroid,  pancreas,  supra- 
renal capsules),  toxaemic  symptoms  appear,  and  it  is  assumed  by  many  that  such 
organs  possess  the  power  of  neutralising  poisonous  substances.  It  may  be  that 
the  phenomena  which  follow  ablation  are  due  to  spontaneous  intoxication,  but 
this  is  by  no  means  universally  accepted. 

The  clinical  picture  of  a  spontaneous  toxaemia  varies  considerably  according 
to  the  nature  and  origin  of  the  poison.  The  physiological  action  of  the  poisonous 
bodies  is  manifold,  and  furthermore  the  poison  may  be  highly  selective ;  thus  it 
may  affect  more  especially  the  heart,  or  the  respiration,  or  the  intestinal  tract, 
the  nervous  system  generally,  or  some  specialised  part,  or  it  may  be  a  general 
tissue  poison.  Again,  the  clinical  picture  must  vary  with  the  dose  of  poison 
absorbed  and  the  acuteness  of  the  absorption.  Hence  the  protean  character  of 
certain  toxaemias,  such  as  uraemia. 

Treatment  of  toxaemia. — (a)  In  the  case  of  a  bacterial  toxaemia, 
the  rational  mode  of  procedure  is  to  search  for  an  antitoxine.  This  can  only 
be  obtained  by  first  subjecting  an  animal  to  a  slow  process  of  intoxication, 
in  order  to  bring  out  a  specific  immunity,  and  to  impart  to  the  serum  anti- 
toxic or  neutralising  properties,  (b)  For  some  of  the  exogenous  poisons  there 
are  true  antidotes,  which,  when  administered  to  a  poisoned  animal,  form  harm- 
less bodies  with  the  toxic  molecules,  and  thus  save  the  animal  from  certain 
death.  This  is  the  ideal  method  of  antitoxic  treatment,  and  is  well  illustrated 
by  the  following  example.  Lang  and  Heymans  have  shown  that  the  nitril  group 
is  highly  poisonous  to  rabbits,  the  toxic  phenomena  no  doubt  being  due  to  the 
hydrocyanic  acid  radical  of  the  nitril.  If,  shortly  before  the  expected  death  of 
the  poisoned  animal,  hyposulphite  of  soda  be  injected,  the  moribund  rabbit 
suddenly  begins  to  improve  and  quickly  revives.  The  neutralisation  of  the  poison 
is  due  to  the  fact  that  the  sulphur  of  the  hyposulphite  combines  with  the  CN  of 
the  nitril.  It  must  be  our  aim  so  to  study  the  chemical  nature  of  the  endogenous 
poisons,  as  eventually  to  obtain  substances  which  neutralise  with  the  same  cer- 
tainty as  sodium  hyposulphite  acts  upon  nitril.  (c)  In  the  toxaemias  which  arise 
from  inadequacy  of  the  thyroid  gland,  the  symptoms  and  effect  of  poisoning  can 
be  removed  by  supplying  the  material  which  is  wanting,  namely,  thyroid  extract. 
This  method  of  treatment  has  been  used  also  for  diabetes,  Addison's  disease,  and 
other  morbid  states  assumed  to  be  due  to  the  abolition  of  the  specific  internal 
secretion  of  certain  glandular  organs,  but  so  far  with  but  little  success,  (d)  In 
cases  of  uraemia,  cholaemia,  or  intestinal  poisoning,  the  only  remedies  at  present 
known  are  those  which  stimulate  excretion  through  the  kidneys,  intestines,  skin, 
etc.  Such  methods  of  treatment  must  necessarily  be  uncertain,  and  they  often 
fail. 

Although  it  is  possible  to  speak  in  no  uncertain  terms  of  autotoxaemia,  it  must 
be  conceded  that  at  present  little  is  known  of  the  poisons  which  are  supposed  to 
be  the  cause  of  the  various  forms  of  intoxication.  Strictly  speaking,  the  separa- 
tion and  determination  of  these  poisons  are  the  necessary  foundation  of  the 
doctrine  of  autotoxaemia,  and  they  must  be  separated — (a)  from  the  seat  of 
lesion  and  from  the  blood,  and  (b)  also  from  the  urine.  But  in  addition  there 
must  be  the  clinical  signs  or  symptoms  of  a  toxaemia.  Here  difficulties  come  in, 
because — (1)  no  poisons  may  be  found  at  the  seat  of  lesions,  as  they  have  already 
been  absorbed  or  secreted,  or,  (2)  as  in  their  passage  through  the  body  to  the 
kidneys,  they  may  have  been  altered  beyond  recognition.  Yet  there  can  be 
but  little  doubt  that  in  diabetic  coma,  uraemia,  eclampsia,  gout,  and  the  coma 
of  cancerous  disease,  acute  yellow  atrophy  of  the  liver,  tetany,  and  other  con- 
ditions, there  is  an  element  of  true  toxaemia,  for — (1)  the  clinical  symptoms  and 
pathological  evidence  are  too  convincing,  and  (2)  the  treatment  of  these  different 
conditions  has  become  more  successful  since  the  principle  of  intoxication  was 
recognised.     Still,  autotoxaemia  must  not  be  made  to  include  too  much.     Thus, 


92  GENERAL  PATHOLOGY  OF  DLSEASE. 

for  the  present,  it  must  be  left  open  whether  the  vertigo  or  asthma  of  gastric 
intestinal  origin,  or  the  convulsions  of  childhood,  the  lesions  and  symptoms  of 
chlorosis,  or  pernicious  anaemia,  are  actually  due  to  a  true  toxaemia,  rather  than 
to  other  influences,  such  as  nervous  reflexes  or  general  organic  and  functional 
changes.  Here  the  guide  must  he  the  clinical  symptoms,  and  the  anatomical 
conditions  found  after  death.  The  absence  of  morbid  changes,  together  with  the 
existence  of  marked  typical  clinical  symptoms  during  life,  must  in  any  given 
case  always  be  strong  evidence  of  a  toxaemia.  Hence,  however  imperfect  our 
present  knowledge  of  autotoxaemia  is  in  many  points,  it  must  be  confessed  that 
certain  conditions  can  best  be  explained,  and  more  successfully  treated,  on  such 
an  assumption.  In  fact,  the  treatment  successfully  adopted  in  such  cases  as 
uraemia,  diabetic  coma,  or  myxoedema,  as  above  mentioned,  is  the  strongest 
evidence  in  favour  of  the  doctrine  of  autotoxaemia.  Thus,  where  an  intoxication 
is  due  to  the  inadequacy  of  an  organ,  its  symptoms  may  be  removed  by  supplying 
the  substances  withheld  from  the  body  by  the  diseased  organ.  This  is  done  in 
myxoedema,  which  can  be  cured  by  injections  of  thyroid  gland  substance ;  when, 
however,  an.  intoxication  is  due  to  an  abnormal  metabolism,  the  rational  treatment 
would  be  either  to  change  the  abnormal  products  into  normal  ones,  or  to  dissolve 
or  remove  the  abnormal  compounds.  This  is  as  yet  impossible,  as  there  are  no 
chemical  agents  capable  either  of  dissolving  out  the  uric  acid,  or  of  permanently 
correcting  the  metabolic  errors  which  find  their  expression  in  the  uric  acid 
diathesis.  "Where  a  toxaemia  depends  upon  a  retention  or  a  production  of  toxic 
substances,  Bouchard's  maxims  must  be  followed — (1)  To  inhibit  the  production, 
retention,  or  absorption  of  the  poisons ;  (2)  to  destroy  them  by  stimulating  these 
organs  whose  function  it  is  to  neutralise  them,  or  by  introducing  chemical  sub- 
stances j  (3)  to  aim  at  promoting  their  secretion  through  the  skin,  lungs,  intestines, 
or  kidneys.  How  to  inhibit  production  or  absorption  is  at  present  unknown,  and 
the  destruction  of  the  poisons  already  formed  or  absorbed  can  only  be  attempted 
by  chemical  substances,  which  act  either  indirectly  upon  them  by  stimulating 
the  toxine-destroying  organ,  or  directly  by  dissolving,  precipitating,  or  combining 
with  the  poisonous  substances  so  as  to  form  atoxic  bodies.  Here,  again,  it  is 
impossible  to  find  substances  which  act  upon  these  unknown  poisons  just  as  the 
hyposulphite  acts  upon  the  toxic  nitril.  Hence  it  only  remains  to  attempt  to 
promote  a  rigorous  excretion  of  the  poisons.  This  excretion  may  be  furthered  by 
diaphoresis  where  the  skin  is  pervious.  Xature  herself  gives  an  indication  of 
this  treatment :  profuse  sweating  accompanies  or  precedes  the  crisis  or  turning 
point  of  several  diseases  which  are  pre-eminently  toxic,  such  as  pneumonia  and 
rheumatic  fever.  In  uraemia  and  eclampsia,  diaphoretics  and  the  vapour  bath  are 
recognised  therapeutic  measures. 

Diuresis  also  is  a  good  protective  against  the  accumulation  of  toxic  substances 
in  the  tissues.  In  uraemia,  diuretics  must  be  employed  if  the  renal  tissues  are 
pervious  ;  in  diabetic  toxaemia,  when  the  urine  excretion  becomes  diminished,  they 
are  employed,  and  so  also  in  severe  febrile  conditions.  In  fact,  whenever  a 
toxaemia  is  accompanied  by  a  progressive  or  sudden  diminution  of  the  secretion  of 
urine  or  by  anuria,  diuretics  are  the  rational  mode  of  treatment.  In  all  chronic 
forms  of  intoxication,  such  as  migraine,  uric  acid  poisoning,  etc.,  copious  diuresis 
is  of  the  greatest  help  in  washing  out  the  poison  or  in  diluting  it ;  this  is  often 
effected  by  copious  draughts  of  suitable  and  especially  warm  drinks. 

A  toxaemia  may  also  be  relieved  by  the  withdrawal  of  blood,  and  this  is  done 
in  uraemia  and  eclampsia,  or  in  slighter  forms  of  intoxication,  such  as  migraine. 
This  may  be  combined  with  infusion  of  saline  solutions,  as  has  been  recently 
practised  in  the  more  acute  toxaemias,  such  as  uraemia. 

"Where  the  forms  and  signs  of  the  poisonous  substances  are  to  be  sought  for  in 
the  intestinal  tract,  it  is  evident  that  an  attempt  should  be  made  to  limit  the 
abnormal  fermentation  process  or  decomposition,  and  to  remove  the  products  of 
these  processes.  This  may  be  done  by  emetics,  the  stomach  pump,  by  laxatives 
and  purgatives,  or  even  by  washing  out  the  intestinal  canal.    Xature's  own  method 


TREATMENT  BY  ORGANIC  EXTRACTS.  93 

of  ridding  the  gut  of  noxious  substances  is  diarrhoea.  Intestinal  antiseptics 
have  been  praised  by  many  writers,  but  it  must  be  clearly  understood  that  it 
is  impossible  to  stop  putrefactive  processes  in  the  human  intestine  by  the 
internal  administration  of  antiseptics.  The  only  method  of  bringing  about  an 
intestinal  disinfection  is  the  removal  of  the  foul  or  noxious  contents,  and  thus  it 
is  that  calomel  has  acquired  the  reputation  of  being  the  best  intestinal  antiseptic ; 
it  acts  not  by  disinfection,  but  by  virtue  of  its  laxative  properties. 

But  even  when  the  source  of  the  poison  is  not  primarily  or  merely  intestinal, 
the  bowel  may  be  used  as  a  channel  along  which  the  toxic  material  may  be 
drained  away  from  the  blood.  The  effect  of  cathartics  is  to  stimulate  a  copious 
flow  of  exudation  from  the  capillaries  into  the  lumen  of  the  intestine,  and  when 
kidneys  and  skin  are  both  impervious,  the  blood  itself  is  the  last  resort.  Thus 
phlebotomy  or  cathartics  are  utilised  in  uraemia,  and  especially  in  eclampsia.  In 
every  case  of  toxaemia,  the  following  points  must  be  considered— (a)  the  cause 
of  poisoning,  and  (b)  the  best  methods  of  either  removing  or  neutralising  the 
poison.  Several  methods  may  have  to  be  considered,  and  due  attention  must 
be  paid  to  the  diseased  organ  or  organs ;  in  fact,  it  is  of  primary  importance  to 
investigate  the  organic  lesions  before  making  a  hypothetical  diagnosis  of  toxaemia, 
for  the  latter  must  never  be  made  without  having  a  clear  understanding  as  to 
where  and  how  it  has  arisen. 


Teeatment  by  means  of  Obganic  Exteacts. 

In  the  previous  section  it  has  been  mentioned  that  some  forms  of  disease 
are  due  to  morbid  changes  in,  or  the  complete  removal  or  exclusion  of,  cer- 
tain glandular  organs,  such  as  the  thyroid ;  and  it  is  generally  assumed  that 
in  such  cases  the  disease  is  of  the  nature  of  a  toxemia.  What  is  the 
evidence,  clinical  and  experimental,  which  proves  that  the  existence  of 
such  glandular  organs  is  necessary  to  the  continuance  of  life  ? 

Thyroid  gland. — Experiments  on  animals,  suggested  through 
observations  on  man,  have  conclusively  shown  that  total  extirpation  of 
the  thyroid  gland,  together  with  the  accessory  glands  or  parathyroids,  is  a 
fatal  operation.  The  symptoms  following  the  removal  may  be  acute  or 
chronic.  In  monkeys,  as  shown  by  Horsley,  when  the  changes  are  acute, 
tremor,  paroxysmal  clonic  spasms,  paralysis,  paresthesia,  sluggish  mental 
operations,  passing  on  to  apathy,  lethargy,  and  coma,  subnormal  tem- 
perature, and  visible  trophic  changes  ensue.  When  the  changes  are 
chronic,  the  monkeys  resemble  cretins,  and  become  dull  of  intellect, 
although  at  times  they  have  periods  of  idiotic  activity.  The  symptoms 
vary  in  different  animals ;  but  it  suffices  to  state  that  total  ablation  of 
the  thyroid  tissue  is  invariably  followed  by  characteristic  symptoms,  and 
in  most  cases  by  death.  Partial  extirpation,  on  the  other  hand,  does  not 
lead  to  disease  or  death,  if  an  adequate  amount  of  thyroid  tissue  is  left, 
so  that,  as  will  be  discussed  more  fully  under  myxoadema,  the  thyroid 
gland  is  a  vital  organ  without  which  life  is  impossible.  By  previous 
successful  implantations  of  thyroid  tissue  in  the  abdominal  cavity,  the 
effects  of  total  removal  may  be  prevented. 

The  changes  produced  in  animals  have  been  explained  as  being  due  to  intoxi- 
cation or  toxaemia,  for  it  has  been  shown  that  the  urine  of  animals  deprived  of 
thyroid  tissue  is  more  toxic  than  that  of  normal  animals,  and  that  the  blood  of 
animals  which  suffer  from  tetany  after  thyroid  ablation,  transfused  into  normal 
animals  produces  tetany  in  them. 

Experiments 'have  also  shown  that  intravenous  and  subcutaneous  injections  of 
an  extract  of  normal  thyroid  tissue  may  remove  the  consequences  of  a  thyroidec- 


94  GENERAL  PATHOLOGY  OF  DLSEASE. 

tomy,  or,  at  any  rate,  keep  them  in  abeyance,  so  that  there  can  he  no  doubt  that 
this  extract  possesses  a  curative  action,  i.e.  that  the  toxic  symptoms  following 
upon  ablation  of  the  thyroid  gland  may  be  neutralised  by  supplying  those 
chemical  substances  of  which  the  removal  of  the  gland  has  deprived  the  tissues 
of  the  animal. 

The  observations  which  have  been  made  on  animals  are  in  close 
agreement  with  those  made  on  man.  Clinical  observations,  medical  and 
surgical,  showed  that  atrophy,  inadequacy,  or  extirpation  of  the  thyroid 
gland  results  in  m'yxcedema  or  a  cretinoid  state,  tetany,  or  cachexia; 
subsequently  animal  experiments  proved  conclusively  the  vital  importance 
of  this  gland.  Further  observation  and  experience  showed  that  the 
lesions  and  symptoms  due  to  inadequacy  of  the  thyroid  gland  may  be 
allayed  or  removed  by  implantation  of  thyroid  tissue,  by  injection  of  an 
extract  of  the  gland,  or  even  by  gastric  administration  of  the  active 
principles.  Hence  it  was  concluded  that  the  thyroid  gland  secretes  a 
substance  which  is  necessary  for  the  proper  metabolic  activity  of  the 
body,  and  that  if  this  substance  is  not  secreted  in  sufficient  quantity, 
it  must  be  artificially  supplied  by  inoculation  or  feeding.  Since  the 
thyroid  gland  has  no  excretory  ducts,  its  secretion  must  be  directly 
absorbed  by  the  lymphatics;  the  product  of  its  activity  is  an  internal 
secretion. 

If  this  internal  secretion  is  absent  or  insufficient,  there  results 
myxoedema,  or  cretinism,  tetany,  or  the  cachexia  thyreopriva.  How 
this  secretion  works  is  at  present  unknown.  At  first  in  the  treatment  of 
the  lesions  produced  by  thyroid  inadequacy  the  whole  thyroid  gland  was 
used,  but  gradually  attempts  were  made  to  obtain  the  active  principle. 
The  thyroid  gland  forms  a  chemical  substance,  probably  an  iodine  com- 
pound, which  is  absorbed  and  is  essential  to  life,  and  when  this  substance 
is  absent  or  insufficient  it  must  be  artificially  supplied.  Inadequacy  of 
the  thyroid  secretion  leads  to  metabolic  disturbances,  which  may  be  acute 
or  chronic.  When  acute,  the  picture  is  one  which  may  well  be  compared  to 
an  intoxication  or  toxaemia ;  and  when  chronic,  to  a  cachexia,  which  after 
all  is  a  form  of  intoxication.  When  the  thyroid  secretion  is  withheld, 
there  follow  trophic  degenerative  changes  in  various  tissues  and  organs, 
the  skin,  and  subcutaneous  tissue,  the  reproductive  organs,  etc. ;  further, 
that  the  administration  of  thyroid  substance  completely  alters  the  meta- 
bolic chemistry  of  normal  or  diseased  man  or  animal,  is  now  undoubted, 
as  may  be  seen  from  the  effects  of  the  thyroid  treatment  in  many  cases 
of  obesity,  in  which  it  may  cause  a  considerable  diminution  of  the  fat  stored 
up  in  the  tissues,  and  from  the  effects  which  occasionally  accompany  the 
administration  of  thyroid  substance  to  normal  individuals.  In  myxoedenia 
the  treatment  causes  a  marked  increase  in  the  nitrogen  elimination,  and 
removes  the  marked  trophic  retrogressive  changes  as  well  as  the  toxic 
symptoms. 

"Whatever  the  final  explanations  may  be,  these  observations  and  facts  afford  a 
new  principle  of  treatment ;  they  have  shown  that  it  is  possible  by  inoculation  or 
feeding  to  artificially  replace  a  substance  which  is  necessary  for  life,  and  which  is 
directly  secreted  into  the  tissues.  Further,  in  the  case  under  discussion,  the  sub- 
stance used  for  treatment  may  be  supplied  by  animals  belonging  to  altogether 
different  species,  although  there  are  distinctions  based  undoubtedly  upon  the 
comparative  chemistry  of  the  thyroid  gland.  Finally,  it  is  obvious  that  the  arti- 
ficial substance  must  be  administered  as  long  as  the  normal  supply  is  inadequate, 
i.e.  at  repeated  intervals  and  for  a  long  period. 


TREA TMENT  B  Y  ORGANIC  EXTRA CTS.  95 

Pancreas; — Observations    and    experiments    of    recent    years   have 
shown  that  the  pancreas  is  a  vital  organ.     Complete  extirpation  of  the 
pancreas  causes  death  of  the  animal  after  a  short  illness,  accompanied  by 
all  the  typical  symptoms  of  diabetes ;  partial  ablation,  however  (leaving 
an  adequate  amount  of  pancreatic  tissue  behind),  is  not  fatal,  and  produces 
no  diabetes.     It  has   also   been   conclusively  proved  that  the  symptoms 
which   ensue   are   not   due   to   the  absence   of   the  ordinary   pancreatic 
secretion  which,  under  normal  conditions,  finds  its  way  into  the  duodenum, 
for  ligature  or  complete  experimental  obstruction  of  the  pancreatic  duct 
does  not  cause  diabetes.     Nor  is  the  experimental  diabetes  due  to  nerve 
lesion,  for  section  of  all  the  nerves  around  the  pancreas  does  not  produce 
it.      Hence  pancreatic  diabetes  must   depend  upon  the  elimination  of  a 
special  function  of  the  pancreas.     Those  who  accept  the  theory  of  the 
glycogenic  function   of   the  liver,  assume   that   normally   the    pancreas 
"secretes  a  substance  which  is  not  discharged  into  the  alimentary  canal, 
but  directly  into  the  tissues  (an   internal   secretion) ;    this   neutralises 
some  other  substance  in  the  blood  which  inhibits  or  prevents  sugar  de- 
composition in   the  tissues,  so  that  when   the  pancreas  is  removed  this 
inhibitory  substance  is  free,  the  sugar  in  the  tissues  is  not  split  up  and 
oxidised,  and  accumulates  in  the  tissues.     This  explanation  is  probably 
incorrect,  because  the  blood  of  a  dog  after  extirpation  of  the  pancreas, 
transfused  into  another  dog,   does  not  produce  diabetes.     Others  again 
have  assumed  that  the  product  of  this  internal  secretion  of  the  pancreas 
is  a  sugar-destroying  ferment  which  passes  into  the  circulation,  so  that 
after  extirpation   of    the   pancreas,   sugar    is   no   longer   destroyed,  and 
accumulates  in  the   tissues;  but  this  theory  is  also  untenable,  because 
ligature  of  the  pancreatic  veins  does  not  produce  diabetes.     Furthermore, 
it  must  be  remembered  that  some  physiologists  and  pathologists,  following 
Pavy,  have  abandoned  the  doctrine  which  gives  to  the  liver  a  glycogenic 
function.     Pavy  believes  that  the  liver,  instead  of  forming  sugar,  prevents 
its   entry   into   the  general  circulation,  and   thus   secures   escape   from 
diabetes,  and  diabetes  is  therefore  a  failure  or  an  impairment  of  the  power 
of  disposing  of  carbohydrate   matter   before   the   general   circulation   is 
reached.     The  exclusion   of   this   special  pancreatic  secretion  or  product 
leads   to    a   gross    disturbance   of    the    metabolism,    and    especially   the 
carbohydrate    metabolism,    sugar    and    a    number    of    other    substances 
accumulate  in   the   tissues,   thus   leading   to   a   congeries   of    symptoms 
characteristic    of    acute    and    fatal   diabetes.      Here    there    is    in    fact 
a  metabolic  toxaemia,  due  to  elimination  or  inadequacy  of   this   special 
pancreatic  function,  which,  like  that  of  the  thyroid  gland,  controls  the 
mechanism  of  the  normal  metabolism.     In   either   case,  if   the   control 
disappears,  incomplete  or  intermediate  metabolic  products  find  their  way 
into  the  blood  stream.     Through  the  elimination  of  the  pancreatic  function 
the  body  becomes  inundated  with  deleterious  and  incomplete  products  of 
its   own   metabolic   activity,  which   normally   are    either  absent   or   are 
present   only  in   minimal  quantity.      They   are   in    pancreatic    diabetes 
accumulated  in  such  amount,  that  they  may  be  found  in  the  blood  and 
urine  in  abnormal  quantities. 

The  results  obtained  in  diabetes  with  administration  of  pancreatic  substance 
are,  however,  in  striking  contrast  to  the  brilliant  success  of  the  specific  thyroid 
treatment  of  inyxoedema.  Experimentally,  also,  all  attempts  at  removal  of  the 
diabetes  produced  by  extirpation  of  the  pancreas  by  means  of  implantation  of 
pancreas  have  failed,  although  Minkowski  succeeded  by  previous  implantation  in 


96  GENERAL  PATHOLOGY  OF  DLSEASE. 

preventing  a  pancreatic  diabetes.  Clinically,  the  administration  of  pancreatic 
substance  has  been  practically  useless,  not  only  in  cases  of  diabetes  which  were 
unaccompanied  by  pancreatic  lesions,  but  also  in  typical  cases  of  pancreatic 
diabetes. 

Suprarenal  glands. — In  recent  years  the  suprarenal  bodies  have 
been  added  to  the  list  of  those  glands  which  possess  an  internal  secretion. 

Experimentally  it  has  been  proved  that  the  suprarenal  glands  are 
vital  organs;  their  complete  removal  causes  death,  though  removal  of 
one  capsule  only  produces  no  ill  effects.  The  injection  of  suprarenal 
extracts  after  complete  extirpation  delays  death.  The  animals  die  with 
symptoms  suggestive  of  intoxication,  and  the  blood  of  an  animal  deprived 
of  its  suprarenal  glands  becomes  toxic,  not  indeed  to  normal  animals, 
but  to  animals  whose  capsules  have  been  removed. 

All  this  is  highly  suggestive  of  an  analogy  between  the  thyroid  gland  and  the 
suprarenal  capsules.  More  recently  the  physiological  action  of  the  suprarenal 
extract  has  been  carefully  studied  by  Oliver,  and  by  Schaf  er  and  his  pupils,  and  they 
have  shown  that  this  extract,  although  fatal  in  large  doses,  in  small  doses  possesses 
extraordinary  powers  as  an  arterio-constrictor,  a  cardiac  tonic,  and  a  muscular 
stimulant.  It  may  be  assumed,  from  these  observations,  that  the  suprarenal 
capsules  secrete  a  useful  stimulant  substance,  or  that  they  are  excretory  organs, 
in  which  case  the  extract  is  a  tissue  poison.  Accordingly,  disease  of  the  supra- 
renal capsules  may  lead  to  symptoms,  either  because  the  toxic  influence  of  the 
secretion  has  been  eliminated,  or  because  certain  poisonous  substances  are  no 
longer  excreted  or  neutralised  and  absorbed.  It  is  striking  that  Addison's  disease 
is  almost  always  accompanied  by  caseous  or  tuberculous  degeneration  of  the  supra- 
renal capsules,  whilst  tumours,  especially  carcinoma,  only  rarely  lead  to  Addison's 
disease.  The  exact  relation  of  the  suprarenal  capsules  to  Addison's  disease  is  as 
uncertain  as  that  existing  between  diabetes  and  the  liver  and  pancreas,  but  some  such 
close  connection  there  must  be.  It  may  be  a  toxaemia  caused  by  the  ehmination  of  a 
specific  function  of  the  suprarenal  capsule,  which,  as  above  explained,  may  be  cither 
secretory  or  excretory  and  antitoxic.  If  this  function  is  antitoxic,  then  it  may 
be  that  the  capsules  are  capable  of  destroying  certain  intermediate  and  incomplete 
metabolic  products  carried  through  them  by  the  blood ;  what  these  products  are, 
it  is  impossible  to  say,  although  it  may  be  noted  that  certain  observers  hold  that 
the  suprarenal  capsules  act  upon  neurin  and  render  it  harmless.  This,  however, 
has  been  strenuously  denied. 

Clinically,  it  may  be  said  that  Addison's  disease  resembles  a  toxaemia  ; 
there  are  always  present  severe  cachexia,  anaemia,  and  other  serious 
disturbances  of  the  general  state  of  nutrition,  and  intense  nervous 
phenomena,  such  as  coma,  delirium,  and  convulsions.  It  is  possible  that 
all  these  toxaemic  symptoms  may  not  be  the  primary  consequences  of 
suprarenal  disease,  but  the  secondary  effects  of  a  general  disturbance  such 
as  may  be  observed  in  a  cancerous  cachexia,  or  of  changes  in  the  nervous 
system.  It  must  be  remembered  that  the  specific  treatment  of  Addison's 
disease  by  means  of  administration  of  suprarenal  extracts,  suggested  by 
the  above  hypothesis  of  an  internal  secretion,  has  so  far  been  useless,  and 
certainly  not  specific.  Amelioration  of  certain  symptoms  has  been  observed 
to  follow  the  administration  of  suprarenal  extract  in  some  cases  of 
Addison's  disease,  but  never  a  cure;  there  is  no  evidence  as  yet  of  any 
specific  effect  in  the  least  comparable  to  that  observed  in  cases  of 
myxoederna  treated  by  means  of  thyroid  substance. 

The  successful  treatment  of  myxcedema  by  means  of  the  administration  of 
thyroid  substance,  and  the  suggestive  experimental  results  obtained  in  animals 


TREATMENT  BY  ORGANIC  EXTRACTS.  97 

after  ablation  of  the  pancreas  and  suprarenal  capsules,  have  established  a  new 
principle  in  therapeutics,  which  consists  in  the  vicarious  supply  of  certain  active 
substances  of  which  the  body  has  been  deprived  either  through  functional  or 
organic  disease.  Misled  by  this  success,  and  beguiled  by  the  enthusiasm  of  serious 
and  sensational  observers,  physicians  and  surgeons  have  rushed  to  the  use  of 
tissue  extracts  of  all  sorts  of  organs  for  the  treatment  of  various  diseases  and 
symptoms,  displaying  thereby  an  ignorance  of  physiological  and  pathological  facts, 
and  an  absence  of  sound  criticism,  worthy  of  the  Middle  Ages.  Cardin  has  been 
prepared  for  the  treatment  of  cardiac  weakness ;  nephrin  for  the  treatment  of  renal 
atrophy ;  an  extract  of  nerves,  spinal  cord,  brain,  and  prostate,  for  diseases  of  the 
nerves,  cord,  brain,  or  prostate ;  and  a  physiologist  has  attempted  to  remove  the 
weaknesses  of  his  old  age  by  using  an  extract  of  the  organ  largely  associated  with 
the  manifestation  of  vital  energy.  It  must  be  remembered,  however,  that 
destructive  lesions  which  have  produced  permanent  changes  and  an  enduring  loss 
of  substance  can  never  be  made  good.  No  amount  of  nervous  tissue  injected  into 
the  body  can  supply  degenerated  nervous  substance,  which  perhaps  has  been 
replaced  by  fibrous  tissue,  whether  this  belongs  to  the  central,  peripheral,  or 
sympathetic  system.  The  specific  organic  treatment  can  only  be  successful  where 
a  functional  loss  of  a  specific  secretion  has  to  be  dealt  with,  i.e.,  there  can  be  no 
hope  of  re-establishing  the  function  of  an  organ  structurally  altered,  which 
depends  on  its  physical  and  anatomical  structure.  Thus,  assuming  that  the 
kidney,  as  has  been  suggested,  possesses  an  internal  secretion,  it  is  also  known  to 
possess  an  excretory  function,  which  depends  on  its  anatomical  configuration. 
In  atrophy  of  the  kidney  there  would  be  impairment  of  its  hypothetical  secretory 
function,  and  of  its  actual  excretory  function.  Injections  of  nephrin  might 
replace  the  former,  but  what  good  could  it  possibly  do  in  the  re-establishment  of 
the  excretory  powers  ?  no  amount  of  nephrin  will  transform  fibrous  tissue  into 
renal  tissue.  The  thyroid  gland  has  a  purely  secretory  function,  and  disease  can 
do  no  more  than  impair  this  secretion ;  the  conditions  are  quite  different  from 
those  found  in  the  kidney. 

There  is,  however,  another  aspect  of  this  question.  The  study  of  the 
various  tissue  extracts  has  demonstrated  that  some  of  them  possess 
striking  properties,  and  again  the  use  of  thyroid  extract  in  myxoedema  has 
revealed  extraordinary  powers  of  this  remedy  to  remove  certain  morbid 
changes  and  symptoms.  Soon,  therefore,  the  question  arose  whether  some 
of  these  substances  might  not  be  used  as  medicinal  agents,  not  specifically 
to  replace  the  functional  loss  of  a  specific  secretion,  but  as  a  drug  for  the 
treatment  of  certain  symptoms.  Thus,  having  learnt  that  thyroid  extract 
causes  a  rapid  loss  of  weight  in  myxoedema,  physicians  have  administered 
it  with  some  measure  of  success  in  obesity.  The  action  of  the  thyroid 
extract  upon  the  skin  of  myxoedematous  patients  suggested  the  treatment 
of  certain  skin  diseases,  such  as  psoriasis  and  lupus,  with  the  same  remedy. 
The  good  effect  upon  the  mental  condition  of  myxoedema  patients  also  led 
to  its  use  in  diseases  of  the  mind.  In  many  cases  the  thyroid  extract 
has  done  good,  although  in  others  it  was  without  effect;  it  may  seem 
justifiable  to  adminster  it  under  certain  conditions,  but  not,  perhaps,  indis- 
criminately until  the  physiological  action  of  the  remedy  is  more  fully 
understood. 

In  conclusion,  then,  it  may  be  affirmed  that  recent  observations 
and  experiments  have  supplied  physicians  with  another  new  method  of 
treatment,  namely,  the  administration  of  organic  extracts.  As  in  the  case 
of  the  serum  treatment,  this  may  be — (1)  specific  (thyroid  extracts  in 
myxoedema  and  other  diseases  due  to  inadequacy  of  thyroid  gland) ;  (2) 
non-specific,  when  these  tissue  extracts  are  used  like  ordinary  drugs  to 
vol.  1  — 7 


98  GENERAL  PATHOLOGY  OF  DLSEASE. 

allay  certain  symptoms  or  to  produce  certain  effects  (suprarenal  extract 
as  a  vasomotor  constrictor),  If  diseases  due  to  functional  loss  of  the 
specific  thyroid  secretion  be  excepted,  the  new  specific  treatment  has  not 
fulfilled  those  promises  which  the  earlier  observations  aroused. 

Preventive  Inoculation. 

The  principles  of  immunisation  are  also  applied  to  the  prevention  of 
disease,  especially  of  epidemic  disease.  Before  the  day  of  pathological 
bacteriology,  Jenner  had  established  protective  inoculation  by  means  of 
attenuated  virus,  more  or  less  empirically,  but  none-  the  less  surely  and 
consciously.  In  medicine,  protective  inoculations  are  used  only  to  a 
limited  extent,  yet  an  acquaintance  with  what  has  already  been  done,  or 
is  being  done,  in  this  direction  is  necessary. 

Inoculation  "with  attenuated  virus. — This  is  exemplified — By  vac- 
cination against  variola  with  cowpox  lymph,  which  must  be  regarded 
as  attenuated  smallpox  virus.  The  success  of  vaccination  is  unquestion- 
able, and  though  many  problems  regarding  the  nature  of  the  virus  yet 
remain  to  be  solved,  this  much  is  certain,  that  though  vaccination  does 
not  supply  a  life-long  protection  (what  method  of  immunisation  does  ?), 
smallpox  runs  a  much  milder  course  in  those  who  have  been  vaccinated, 
and  among  them  the  mortality  is  considerably  reduced.  Thus,  according 
to  Koch's  statistics,  of  27,794  non-vaccinated  smallpox  patients,  32  per 
cent,  died ;  while  of  181,000  vaccinated  ones,  9*5  per  cent,  died ;  and  of  6015 
revaccinated  ones,  only  7 '4  per  cent.  In  the  case  of  vaccinia  the  attenua- 
tion is  produced  by  passage  through  the  animal  body. 

Tor  hydrophobia  Pasteur  practised  another  method  of  attenuation. 
The  virus  of  this  disease  is  as  little  known  as  that  of  smallpox,  yet  the 
French  master  showed  that  by  drying  the  virus  of  rabies,  contained  in  full 
power  in  the  spinal  cords  of  rabbits,  it  can  be  weakened  to  almost  any 
desired  degree,  and  then  used  for  the  purpose  of  vaccination.  It  may  be 
used  even  during  the  long  incubation  period  that  occurs  after  infection. 
The  mortality  from  hydrophobia  has  been  considerably  reduced  by  this 
prophylactic  treatment,  and  with  improvements  in  the  methods  the 
mortality  has  steadily  decreased  from  0-94  per  cent,  in  1886  to  0'32  per 
cent,  in  1890. 

In  the  protection  against  smallpox  and  rabies,  materials  are  used  that 
are  taken  directly  from  the  animal  body,  and  of  the  virus  itself  nothing 
certain  is  known.  The  principle  has  of  late  years  been  extended  by  Haff- 
kine  in  his  anticholeraic  vaccination. 

Inoculation  with  dead  or  living  pure  cultures. — Haffkine  origin- 
ally used  an  inoculation  in  cholera  of  attenuated  living  cultures  of 
cholera  vibrios  as  his  first  vaccine,  which  was  then  followed  by 
an  inoculation  of  highly  virulent  cholera  vibrios,  used  as  a  second 
vaccine.  This  method  has  been  modified  by  him  in  course  of  time, 
so  that  at  present  only  unaltered  virus  is  used,  but  his  original 
method  was  essentially  the  same  in  principle  as  that  practised  in  the 
case  of  anthrax.  His  results  have  been  highly  satisfactory.  Thus 
in  Calcutta  Haffkine  found  that  the  mortality  among  the  inoculated 
was  17'24  times  less,  and  the  incidence  of  cholera  19*27  times  less  than 
among  the  non-inoculated ;  evidence  certainly  in  favour  of  the  anticholeraic 
vaccination.  This  evidence  has  recently  become  still  stronger  through  the 
researches  of  Koch,  who  has  shown  that,  as  the  result  of  Haffkine's  method 


PREVENTIVE  INOCULATION.  99 

of  vaccination,  the  bactericidal  power  of  human  serum  grew  3500-fold,  and 
that  after  a  year  it  was  still  twenty  times  as  great  as  that  of  normal 
serum. 

It  has  been  attempted  or  suggested  to  protect  persons  against  plague 
or  enteric  fever  by  using  sterilised  cultures  of  the  plague  or  typhoid 
bacillus  respectively,  administering  the  material  by  subcutaneous  inocula- 
tion. In  both  cases  the  results  have  been  promising,  but  more  actual 
evidence  of  the  value  of  the  method  is  still  wanted.  It  is  reasonable  and 
also  humane  in  times  of  epidemics  to  practise,  along  with  all  possible 
general  measures,  such  preventive  inoculations  as  are  based  upon  sound 
laboratory  experiments;  which,  properly  carried  out,  can  do  no  harm 
beyond  giving  slight  temporary  and  local  inconvenience. 

Inoculation  •with  antitoxic  serum. — The  previously  mentioned 
methods  are  all  instances  of  active  specific  immunisation,  but  the  principle 
of  passive  specific  protection  by  means  of  immunising  serum  has  also 
been  applied,  notably  in  the  prophylaxis  against  diphtheria.  Here  it  is 
recommended  to  inject  150-250  units.  The  statistics  reported  by  Dr. 
Hermann  Biggs  are  in  favour  of  the  use  of  these  preventive  inoculations  for 
the  purpose  of  protecting  a  household  or  a  community.  Although  it  may 
be  difficult  to  gain  absolute  certainty,  Dr.  Biggs  writes  that  by  the  use 
of  diphtheria  antitoxine  in  four  great  institutions  for  children  in  New 
York,  in  which  diphtheria  was  prevailing  in  epidemic  form,  it  has  been 
possible  to  completely  stamp  out  the  disease.  Serious  results  have 
never  resulted  from  the  injections,  but  the  immunity  only  lasts  for  from 
two  to  four  weeks.  With  regard  to  tetanus,  preventive  inoculations 
with  antitoxine  have,  according  to  Nocard,  been  successful  in  horses; 
but  in  man  the  few  observations  recorded  do  not  seem  promising,  probably 
because  of  the  transitory  nature  of  the  passive  immunity  and  the  un- 
certainty of  an  existing  infection.  Nevertheless,  these  methods  of 
passive  immunisation  where  occasion  arises  for  their  use  are  worthy  of  all 
consideration,  especially  if  the  patient  can  be  treated  as  soon  as  he  is 
wounded  or  bruised. 

(A.  A.  KANTHACK.) 


[The  late  Professor  Kanthack  was  engaged  on  this  article  at  the  time  of  his 
death.  Certain  parts  were  completed ;  others  had  been  drafted  hut  had  not  been 
arranged  and  filled  in ;  of  others,  again,  there  were  but  rough  notes.  The 
completed  portion,  especially  that  dealing  with  inflammation  and  repair,  has 
been  left  unaltered  (except  that  it  has  been  condensed),  and  represents  his  latest 
opinions  on  these  subjects.  Throughout  the  article  an  attempt  has  been  made 
to  reproduce  from  his  numerous  papers  and  the  recollections  of  certain  of  his 
friends  any  special  views  that  he  held.  For  portions  of  the  work  to  which 
Professor  Kanthack  had  paid  no  special  attention,  or  on  which  he  left  no  full 
notes,  or  none  at  all,  I  must  hold  myself  responsible. 

G.  SIMS  WOODHEAD.J 


SECTION    I. 

GENERAL   DISEASES. 


TYPHUS  FEVER 
Syn.,  Fr.,  Typhus  exanthe'matique ;  Ger.,  Fleckfieber. 

An  acute  specific  infectious  fever,  prevailing  in  epidemics  and  usually 
associated  with  conditions  of  overcrowding  and  destitution.  Characterised 
by  a  sudden  onset,  a  petechial  rash,  marked  nervous  symptoms,  with  great 
mental  confusion  and  physical  prostration,  and  by  a  rapid  defervescence 
on  or  about  the  fourteenth  day. 

History, — There  is  very  little  doubt  that  this  disease  has  been 
known  from  the  earliest  times.  It  is  highly  probable  that  typhus  was 
the  epidemic  which  ravaged  Athens,  as  described  by  Thucydides.  We 
may  also  assume  that  typhus  fever  was  the  disease  which  so  frequently 
broke  out  in  camps  and  armies  in  the  Middle  Ages.  No  doubt  a 
proportion  of  such  cases  were  typhoid,  as  it  is  only  comparatively 
recently  that  these  two  fevers  have  been  recognised  as  distinct  from  one 
another.  But  the  conditions  under  which  these  epidemics  arose  were 
undoubtedly  such  as  to  favour  the  outbreak  of  typhus.  Indeed, "  camp 
fever  "  is  one  of  the  many  names  which  have  been  given  to  it.  It  has  also 
merited  the  name  of  "jail  fever,"  as  in  the  seventeenth  and  eighteenth 
centuries  it  repeatedly  broke  out  and  spread  with  frightful  rapidity  in 
the  overcrowded  prisons  in  this  country.  Although  very  many  observers 
before  him  had  rendered  full  accounts  of  typhus,  and  had  distinguished  it 
from  both  typhoid  and  relapsing  fevers,  it  is  to  Murchison  we  are  indebted 
for  the  best  description  hitherto  given  of  the  disease. 

As  regards  geographical  range,  typhus  has  at  different  periods  been  seen 

all  over  Europe.     It  is  uncommon  in  the  tropics,  and  it  is  suggested  that 

the  conditions  of  life  in  temperate  climates,  where  during  the  winter  people 

are  more  likely  to  crowd  together  to  avoid  cold,  are  more  favourable  to  its 

development.     The  two  countries  which  have  suffered  most  from  it  in  this 

century  are  Russia  and  Great  Britain ;  and  although  modern  sanitation  has 

made   a  great  epidemic  in  this  country  almost  impossible,  still  small 

outbreaks   do  occur  occasionally.     Ireland  has  long  had  an   unenviable 

notoriety   for  the  prevalence  of  the  disease,  and  it  has  been  said  to  be 

endemic  in  the  narrow  closes  of  the  Old  Town  of  Edinburgh.     The  latter 

100 


TYPHUS  FEVER.  101 

statement  is  not  justifiable,  as,  though  outbreaks  occasionally  do  occur,  they 
can  nearly  always  be  traced  to  importation  from  an  outside  source. 

Etiology. — That  the  exciting  cause  of  typhus  is  a  micro-organism  of 
some  description,  there  can  be  no  reasonable  doubt,  but  hitherto  it  has  not 
been  discovered.  Thoinot  and  Calmette  have  described  bodies  resembling 
human  spermatozoa  in  the  blood  of  typhus  patients,  but  their  observations 
have  never  been  confirmed.  Hlava  of  Prague  described  a  streptobacillus 
in  1891,  but  his  work  also  requires  proof.  Dubief  and  Bruhl  made  a 
bacteriological  research  into  some  cases  which  occurred  in  the  prisons 
of  Paris  in  1893.  They  found  post-mortem  a  diplococcus  in  the  lungs 
and  bronchial  secretion.  Lastly,  Balfour  and  Porter,  during  a  recent 
outbreak  in  Edinburgh,  described  a  diplococcus  which  differed  in  many 
respects  from  that  of  the  French  observers.  It  was  found  both  post- 
mortem and  in  the  blood  during  life.  It  is  too  early,  however,  at  present 
to  claim  the  micro-organism  they  have  discovered  with  any  confidence  as 
the  cause  of  the  disease.  The  possibility  of  the  origin  of  typhus  de  novo  is 
not  now  admitted. 

The  predisposing  causes  of  typhus  are  overcrowding  and  conditions 
which  lead  to  overcrowding.  Starvation  is  also  said  to  predispose,  and 
obviously  such  a  contagious  disease  would  spread  more  rapidly  in  periods 
of  famine,  when  the  resisting  power  of  the  population  is  lowered.  But  if 
half -starved  people  lived  under  favourable  sanitary  conditions,  there  is  no 
reason  to  believe  that  the  disease  could  spread.  In  regard  to  season  as  a 
predisposing  cause,  it  is  in  the  winter  months  that  typhus  is  most  common, 
since  it  is  at  that  time  windows  are  kept  shut  and  the  poor  huddle  together 
for  warmth.  Mental  and  physical  fatigue  and  ill  health  may  also  be 
regarded  as  secondary  predisposing  causes. 

Dissemination. — Typhus  fever  is  directly  contagious  from  person  to 
person.  Nurses  from  their  close  attention  on  patients  are  very  liable  to 
take  it.  Physicians  also,  especially  if  they  attend  the  patients  in  their  own 
homes,  run  a  considerable  risk.  In  hospitals,  however,  if  sufficient  atten- 
tion is  paid  to  free  ventilation,  accidents  of  this  kind  are  uncommon.  It 
would  seem,  indeed,  that  a  certain  concentration  of  the  poison  is  necessary 
to  cause  infection,  and  that  the  unknown  germ  of  the  disease  cannot  exist 
in  fresh  air.  The  "  striking  distance  "  of  typhus  is  a  very  short  one.  It 
is  probably  necessary  to  be  in  absolute  contact  with  the  patient  or  to  enter 
an  unventilated  room  in  which  a  patient  is  lying.  Harvey  Littlejohn, 
in  investigating  the  spread  of  the  last  outbreak  in  Edinburgh,  proved 
conclusively  that,  even  in  large  overcrowded  tenements  where  several 
families  occupied  different  rooms  on  the  same  flat,  the  disease  did  not 
spread  from  one  family  to  another  unless  they  were  in  the  habit  of  entering 
each  other's  rooms.  The  people  who  were  not  on  intimate  terms  with  the 
infected  families  escaped,  although  their  rooms  opened  into  the  same  narrow 
and  imperfectly  ventilated  landing.  The  poison,  however,  susceptible  as  it 
is  to  fresh  air,  can  retain  its  virulence  for  a  long  time  in  houses  that 
have  not  been  disinfected  or  thoroughly  aired.  Old  clothes  and  bedding 
have  been  on  more  than  one  occasion  the  cause  of  an  outbreak,  and  the 
mere  handling  of  them  to  prepare  them  for  disinfection  has  given  sanitary 
officials  the  disease. 

Morbid  anatomy. — Typhus  cannot  be  said  to  have  any  character- 
istic post-mortem  appearance.  Decomposition  sets  in  early,  and  the 
autopsy  should  be  made  as  soon  as  possible.  All  the  internal  organs  are, 
as  a  rule,  congested,  and  sometimes  small  haemorrhages  may  be  seen  on 


102 


GENERAL  DISEASES. 


their  surfaces.  The  heart's  substance  is  soft  and  friable,  and  its  cavities 
are  somewhat  dilated.  The  myocardium  presents  the  characters  of  an 
acute  parenchymatous  degeneration.  Microscopically,  the  muscular  fibres 
show  cloudy  swelling,  along  with  loss  of  striation  and  the  presence  of  fat 
granules.  The  blood  is  dark  and  fluid.  The  lungs  show  great  hypostatic 
congestion,  often  with  consolidation  at  the  base.  The  spleen  is  enlarged, 
very  soft,  and  occasionally  diffluent.  The  membranes  of  the  brain  are 
congested,  and  the  lateral  ventricles  are  often  distended  with  fluid.  The 
intestine  shows  no  internal  ulceration,  though  occasionally  small  ulcers 
have  been  seen  in  the  stomach.  There  is  then  no  sign  by  which  the 
disease  can  be  recognised  after  death,  though  of  course  the  existence  of 
genuine  petechias  on  the  skin,  with  the  appearance  detailed  above,  would 
afford  a  strong  presumption  that  the  case  was  one  of  typhus. 

Symptoms  and  course. — The  period  of  initiation  appears  in 
most  cases  to  be  about  twelve  days.  It  is  often  a  matter  of  difficulty  to 
determine  this  period  accurately,  but  it  would  seem  rarely  to  exceed  that 
time.  Not  a  few  instances  are  on  record  where  a  much  shorter  incubation 
appeared  probable.     During  this  period  there  are  no  well-defined  symptoms. 

This  fever  being  one  of  a  fortnight's  duration,  it  will  be  convenient  in 
a  general  description  to  consider  the  symptoms  as  presented  during  each 
of  the  two  weeks  of  its  progress. 


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1 

1 

Fig.  1. — A,  Fatal  case  of  typhus  in  a  male  adult ;  B,  C,  and  D,  Examples  of  the  temperature 
curve  during  the  period  of  invasion. 

The  Events  of  the  First  Week. — The  invasion  of  typhus  fever  is 
on  the  whole  pretty  well  marked,  thus  differing  from  that  of  typhoid. 
A  rigor,  but  perhaps  more  frequently  sensations  of  chilliness,  distinct 
and  recurring,  usher  in  the  attack.  The  onset  is  followed  by  headache, 
which  is  a  very  constant  symptom.  It  is  frontal  for  the  most  part,  and  is 
usually  severe,  sometimes  agonising.  Pains  in  the  back  and  limbs,,  or 
soreness  all  over,  are  also  present,  and  there  is  restlessness  and  disturbed 
sleep.  The  temperature  rises  to  a  high  point  (102°  to  103°)  from  the  first 
day,  and  continues  to  rise  for  several  days,  while  there  is  little  or  no 
morning  remission ;  the  pulse  is  frequent  and  full,  and  the  respirations 
are  increased  in  rate.  A  sense  of  prostration  is  a  prominent  symptom 
from  the  outset,  and  the  patient  is  compelled  to  take  to  bed.  The  face  is 
flushed,  the  eyes  red,  the  pupils  somewhat  contracted,  and  there  is 
photophobia.  The  tongue  is  at  first  thickly  coated,  but  it  soon  becomes 
dry,  and  there  is  thirst,  loss  of  appetite,  and  constipation. 


TYPHUS  FEVER. 


103 


These  various  symptoms  may  readily  be  mistaken  for  some  other  febrile 
affection  during  the  few  days  of  their  continuance,  but  soon  the  more 
characteristic  features  of  the  fever  declare,  themselves.  On  the  fourth  or 
fifth  day  there  usually  appears  the  eruption  of  typhus.  It  consists  of  spots 
of  irregular  size  (from  1  to  3  or  4  lines  in  diameter),  of  pale  pink  colour, 
with  ill-defined  edges,  slightly  raised  above  the  skin,  and  at  first  disappear- 
ing on  pressure.  The  spots  are  isolated  or  gathered  in  groups,  and  are 
first  seen  about  the  anterior  folds  of  the  axillae,  on  the  backs  of  the  hands 
and  of  the  elbows,  and  then  upon  the  chest,  abdomen,  and  flanks ;  but  they 
soon  spread  more  or  less  over  the  whole  body  and  limbs.  They  are  not  so 
noticeable,  although  they  are  often  present,  on  the  face.  In  addition 
to  these  spots,  there  is  an  irregularly  congested  condition  of  the  skin,  giving 
to  it  a  somewhat  marbled  appearance  (subcuticular  mottling).  The  spots, 
which  have  at  first  a  certain  resemblance  to  a  fading  measles  eruption, 
tend  to  become  darker  in  colour,  and  acquire  an  appearance  a  little 
suggestive  of  flea-bites,  all  the  more  so  that  in  the  centre  of  some  of 
them  may  be  observed  a  slightly  darker  point — a  minute  extravasation ; 
but  their  want  of  definition  at  the  margins  is  an  important  distinction. 


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Fig.  2. — A,  A  case  of  typhus  in  a  young  adult ;  B  and  C,  Examples  of 
termination  by  crisis. 

The  spots  and  the  mottling  together  constitute  what  is  termed  by  Sir 
William  Jenner  the  "  mulberry  rash  "  of  typhus.  Although  in  some  cases 
this  rash  is  so  small  in  amount  as  to  be  with  difficulty  detected,  it  is 
extremely  seldom  absent,  except  in  young  children.  The  later  days  of  the 
first  week  are  marked  by  an  increase  in  the  febrile  symptoms  and  by 
advancing  prostration  of  strength.  The  temperature  continues  high  (103° 
to  105°);  the  pulse  becomes  more  frequent  and  feeble;  the  tongue  is  dry 
and  brown,  and  sordes  accumulate  on  the  teeth.  The  urine  is  scanty  and 
high-coloured,  and  often  contains  a  little  albumin.  The  breath  and  the 
body  exhale  a  peculiar  odour,  which  has  been  held  by  some  to  possess 
diagnostic  importance.  The  patient  now  has  a  dull,  heavy,  dusky  aspect. 
He  complains  less  of  headache,  and  is  somewhat  drowsy,  but  can  easily 
be  roused  when  spoken  to  loudly,  for  there  is  some  dulness  of  hearing. 
Delirium  may  be  present,  particularly  at  night. 

The  Events  of  the  Second  Week. — The  symptoms  now  assume  a 
character  more  truly  typical  of  this  fever.  The  patient  becomes  utterly 
prostrate,  and  insensible  to  everything  around  him  and  to  his  own  wants. 
He  lies  low  in  bed  with  his  eyes  closed,  and  the  appearance  of  being  in  a 


io4 


GENERAL  DISEASES 


deep  sleep  or  stupor  from  which  he  cannot  be  fully  roused,  although  in 
general  he  can  be  persuaded  to  take  food.  His  face  is  darkly  congested,  or 
more  rarely  pallid,  and  his  breathing  is  frequent  and  audible.  Delirium, 
usually  of  a  quiet  muttering  character,  is  present.  Occasionally  it  is  busy, 
noisy,  or  violent.  The  hands  are  moved  aimlessly  about  or  pick  at  the 
bedclothes,  while  the  tremors  of  the  muscles  and  subsultus  tendinum 
indicate  the  great  nervous  and  muscular  weakness  to  which  the  patient  is 
reduced.  The  temperature  may  have  slightly  subsided  after  the  sixth 
day,  but  it  still  continues  high,  and  the  pulse  becomes  more  rapid  (120 
to  130)  and  feeble.  There  is  usually  retention  of  urine.  For  several 
days  the  patient  may  remain  in  this  condition  without  much  change,  or 
again  the  symptoms  may  advance,  and  death  ensue  from  sheer  exhaustion 
or  from  deepening  coma,  accompanied  with  pulmonary  engorgement. 
Occasionally,  sudden  heart  failure  precipitates  the  end. 

In  most  cases,  however,  a  favourable  change  begins  to  show  itself 
about  the  end  of  the  second  week  (usually  the  fourteenth  day),  when  there 
occurs  the  phenomenon  of  the  crisis  which  forms  so  striking  a  feature  in 
the  clinical  history  of  a  case  of  typhus.  The  temperature  falls  rapidly, 
often  reaching  the  normal  point  in  less  than  twelve  hours;  the  pulse 
becomes   slower  and   better  in  character;   a  gentle  moisture  appears  on 

the  skin,  and  the 
patient  seems  to  be 
in  a  more  natural 
sleep,  from  which 
he  awakes  looking 
much  brighter. 
This  change  in  the 
face  is  very  signifi- 
cant of  the  crisis. 
The  tongue  can  now 
be  more  readily  pro- 
truded, and  is  moist 
at  the  edges.  The 
urine  is  more  abun- 
dant, and  is  loaded 
with  urates.  The  patient  shows  signs  of  returning  consciousness,  although 
there  may  still  be  some  delirium  and  confusion.  Notwithstanding  a 
feeling  of  extreme  weakness,  convalescence  is  soon  established,  and 
proceeds  rapidly,  being  rarely  interrupted ;  as  a  rule,  recovery  is  complete 
in  three  or  four  weeks  after  the  crisis. 

The  patient  may  have  no  recollection  of  his  illness,  or  it  may  be  in  his 
memory  as  a  vague  dream.  Sometimes  he  imagines  himself  to  have  been 
away  on  a  long  journey,  and  is  able  to  recall  its  incidents.  Occasionally, 
on  the  other  hand,  his  fancies  have  been  of  a  distressing  or  agonising 
character,  the  memory  of  which  remains  even  long  after  recovery. 

Analysis  of  some  of  the  chief  symptoms,  including  complications. — 
The  febrile  symptoms. — The  temperature  rises  rapidly  from  the  onset  of 
the  attack,  and  even  on  the  first  day  may  be  102°  or  103°.  It  continues 
rising  slightly  during  the  greater  part  of  the  first  week,  by  the  end  of 
which  it  has  usually  attained  its  maximum  point,  which  in  an  average 
case  rarely  exceeds  105°,  except  in  the  case  of  children,  in  whom  it  may 
be  higher.  There  is  very  slight  if  any  morning  remission.  In  the  second 
week   of   the   fever  the   temperature   may  show  a  slightly  lower   level, 


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v. 

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J 

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Fig.  3. — Complete  course  of  typhus  in  a  child,  set.  4. 


TYPHUS  FEVER. 


io5 


but  it  still  continues  high  until  about  the  twelfth  or  thirteenth  day, 
when  it  begins  to  move  a  little  either  in  the  upward  or  downward 
direction.  This  occurs  prior  to  the  crisis,  which,  as  already  mentioned,  is 
recognised  partly  by  the  rapid  descent  of  the  temperature  to  normal. 

A  very  high  temperature  (over  105°)  in  the  first  week,  especially  if 
accompanied,  as  it  often  is,  with  head  symptoms,  marks  a  severe  and 
anxious  case,  and  the  same  may  be  said  of  those  attacks  in  which  the 
temperature  of  the  second  week  exceeds  that  of  the  first.  The  temperature, 
however,  is  not  an  absolutely  reliable  indication  of  the  severity  of  a  case, 
but  must  be  considered  along  with  the  pulse  and  other  symptoms,  par- 
ticularly those  relating  to  the  nervous  system.  Thus  a  case  may  show 
no  unusual  course  of  the  temperature,  and  yet  be  of  most  unfavourable 
prognosis,  owing  to  its  adynamic  character,  the  pulse  being  small  and 
frequent,  and  the  delirium  and  prostration  very  pronounced.  Hyperpyrexia 
is  rarely  met  with  in  this  fever,  although  in  fatal  cases  there  may  be 
a  swift  rise  of  temperature  to  a  very  high  point  shortly  before  death. 
Complications  may  influence  the  course  of  the  temperature,  and  render  it 
less  typical  of  the  fever.  In  some  instances,  particularly  among  children, 
defervescence  may  take  place  by  lysis,  and  the  case  go  on  for  sixteen  or 


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S 

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A  B 

Fig.  4. — A,  Complete  course  of  typhus  in  a  woman,  set.  67  ;  B,  Rare  instance  of 
termination  by  lysis. 

more  days  before  the  normal  temperature  is  reached.  Afebrile  cases  of 
typhus  have  on  rare  occasions  been  met  with.  Sometimes  a  final  crisis 
occurs  at  the  end  of  the  first  or  beginning  of  the  second  week. 

Circulatory  System. — The  pulse  is  quickened  from  the  first  (100  to 
120),  thus  presenting  a  contrast  to  typhoid  fever,  in  which  it  is  often 
comparatively  infrequent  at  this  period.  But  the  relation  of  pulse  and 
temperature  is  not  absolute  in  typhus.  At  the  outset  the  pulse  is  full 
and  soft,  but  it  soon  loses  this  character,  becoming  small  and  frequent, 
particularly  during  the  second  week,  when  low  tension  and  dicrotism  are 
often  marked.  A  pulse  rate  over  120  in  an  adult  generally  indicates 
an  anxious  case,  and  where  it  exceeds  130  the  mortality  is  very  high 
Unsteadiness  or  irregularity  of  the  pulse,  as  the  fever  approaches  the 
crisis,  is  often  of  evil  omen.  Cases  of  unusually  rare  pulse  have  been 
observed  by  Murchison,  Maclagan,  and  others,  in  which  the  rate  was 
below  40  or  even  below  30.  In  some  of  these  cases  the  infrequency 
continued  only  for  a  few  days ;  in  others  there  was  a  want  of  synchronism 
between  the  radial  and  cardiac  pulse  rate,  the  former  showing  only  one 
pulsation  for  two  of  the  latter.  Unusually  rare  pulses  generally  testify 
to  marked  cardiac  weakness,  and  the  prognosis  in  such  cases  is  not 
favourable. 


'io6  GENERAL  DISEASES. 

After  the  crisis  is  past  the  pulse  may  subside  to  a  very  low  rate, 
and  while  such  a  condition  is  generally  only  temporary,  it  is  not  without 
its  risks,  and  requires  while  it  lasts  special  care,  particularly  as  regards 
exertion  on  the  part  of  the  patient. 

The  physical  examination  of  the  heart  is  of  great  importance.  In 
most  cases,  as  the  fever  advances  and  the  heart's  action  becomes  more 
rapid,  a  diminution  in  the  force  of  the  cardiac  impulse  is  perceptible, 
and  the  first  sound  at  the  apex  becomes  less  clear,  or  almost  inaudible, 
the  second  sound  being  by  contrast  sharp  and  distinct.  A  soft  blowing 
murmur  may  occasionally  be  heard  at  the  apex.  The  cardiac  condition 
during  the  progress  of  the  fever  claims  the  special  attention  of  the 
physician,  as,  owing  to  the  changes  which  affect  the  myocardium,  heart 
failure  is  a  danger  to  be  feared. 

Respiratory  System. — The  respiration  is  more  or  less  increased  in 
frequency  in  typhus  as  in  all  fevers.  In  mild  cases  this  increase  may 
not  be  very  great,  but  in  general  during  the  second  week  a  marked 
acceleration  takes  place,  the  rate  rising  to  30,  40,  50,  or  more.  The 
breathing  is  short,  shallow,  and  audible.  When  insensibility  comes  on,  a 
puffing  or  hissing  character  of  the  respiration  may  be  observed,  as  in 
comatose  conditions,  with  increasing  duskiness  of  the  face.  Marked 
irregularity  of  respiration  is  an  unfavourable  sign. 

Some  amount  of  bronchial  catarrh  is  very  common,  and  shows  itself 
by  slight  cough  and  by  the  presence  of  sonorous  and  sibilant  sounds  all  over 
the  chest.  Hypostatic  congestion  of  the  lungs,  while  probably  present  to 
a  certain  extent  in  all  cases,  frequently  assumes  the  character  of  a 
dangerous  complication.  Depending  in  great  measure  upon  the  increasing 
cardiac  weakness,  it  may  also  be  predisposed  to  by  the  shallow  character 
of  the  febrile  breathing  already  described,  and  by  the  decubitus  of  the 
patient.  It  is  most  apt  to  be  present  during  the  second  week  of  the 
fever.  It  reveals  itself  by  quickened  breathing,  cyanosis,  and  feeble 
cardiac  action.  Cough  may  or  may  not  be  present.  The  physical 
examination  shows  evidence  of  pulmonary  engorgement  and  oedema, 
by  the  impaired  percussion  note  at  the  bases  of  the  lungs  or  all  over 
posteriorly,  together  with  faintness  of  the  vesicular  breathing,  and  the 
presence  of  medium  crepitating  rales  and  sonorous  and  sibilant  rhonchi. 
In  not  a  few  instances  this  complication  has  a  large  share  in  bringing 
about  a  fatal  result. 

True  pneumonia  rarely  accompanies  typhus  fever,  but  when  it  does 
occur  it  is  a  grave  complication,  both  in  itself  and  from  the  risk  of 
gangrene  of  the  lung.  Laryngitis  is  an  occasional  complication  of  typhus, 
and  is  always  to  be  regarded  with  anxiety,  from  the  danger  of  acute  oedema 
glottidis. 

Alimentary  System. — The  tongue  is  at  first  moist  and  covered  with 
a  thick  fur,  and  in  mild  cases  may  remain  in  this  condition  throughout. 
Usually,  however,  by  the  end  of  the  first  week  it  has  become  small, 
rough-looking,  dry,  and  covered  with  a  brown  and  cracked  incrustation. 
The  condition  of  the  tongue,  together  with  the  increasing  apathy  and 
deafness  of  the  patient,  renders  its  protrusion  difficult,  so  that  it  is  not 
always  possible  to  obtain  a  good  view  of  it.  Sordes  accumulate  on  the 
teeth  and  lips  as  well  as  the  tongue,  particularly  during  the  second  week, 
and  impart  a  dark  appearance  to  the  mouth. 

Thirst  is  a  prominent  symptom  at  the  beginning,  but  later  on  is  not 
complained  of,  although  as  a  rule  the  patient  readily  takes  liquids.     There 


TYPHUS  FEVER.  107 

is  loss  of  appetite  from  the  first,  but  after  the  crisis  it  speedily  returns 
and  as  a  rule  is  a  good  sign  of  convalescence.  Gastric  irritation  in  the 
form  of  vomiting  is  an  occasional  occurrence,  but  it  rarely  continues  long. 
It  sometimes  ushers  in  a  severe  case.  The  intestinal  symptoms  are  not 
marked  in  typhus.  Constipation  is  the  rule,  although  sometimes  the 
bowels  act  quite  naturally.  Diarrhoea  is  very  rare,  but  it  sometimes 
occurs  at  the  time  of  the  crisis.  There  is  little  abdominal  pain  or  swelling, 
but  occasionally  there  is  tenderness  on  pressure  in  the  right  hypochondrium. 
Both  liver  and  spleen  are  slightly  enlarged. 

Urinary  System. — The  urine  is  at  first  reduced  in  amount  and  dark 
in  colour.  Its  specific  gravity  is  higher  than  normal  (1025  to  1030). 
In  the  later  stages  of  the  fever  the  urine  often  returns  to  its  normal 
character,  although  there  is  very  frequently  retention,  necessitating  the 
use  of  the  catheter.  On  the  occurrence  of  the  crisis  it  contains  a  large 
quantity  of  urates. 

The  proportion  of  urea  is  largely  increased  during  the  first  week  of  the 
fever.  In  the  second  week  it  may  still  continue  high,  but  in  some  cases  it 
is  found  to  have  fallen  to  the  normal  amount  or  even  below  it.  It  seems 
not  improbable  that  in  such  instances  its  elimination  is  insufficient. 
About  the  time  of  the  crisis  the  amount  of  urea  may  again  become 
increased,  but  when  convalescence  is  established  it  gradually  returns 
to  its  normal  proportion. 

Symptoms  of  ursemia  may  arise  in  the  course  of  typhus,  and  the 
danger  of  this  is  greatest  where  the  urine  is  greatly  diminished  or  sup- 
pressed. It  has  been  suggested  by  Murchison  and  other  observers,  that 
the  head  symptoms  of  typhus  may  be  largely  due  to  uraemia  rather  than  to 
any  inflammatory  or  congestive  condition  of  the  brain  and  its  membranes. 
The  uric  acid  is  increased.  The  chlorides  are  diminished  or  absent  during 
the  progress  of  the  fever,  but  return  when  convalescence  sets  in. 

Albumin  is  present  in  greater  or  less  amount  in  a  large  proportion 
of  the  cases  of  typhus.  It  is  usually  of  so-called  febrile  character,  dis- 
appearing after  the  crisis.  But  it  would  appear  in  not  a  few  instances  to 
be  due  to  an  accompanying  complication  of  acute  nephritis,  as  proved  by 
the  presence  of  blood  and  of  tube  casts  in  the  urine,  as  well  as  by  post- 
mortem evidence.  In  a  considerable  number  of  cases  of  typhus  the  urine 
gives  the  "  diazo "  reaction,  thus  proving  the  unreliability  of  this  test  as 
diagnostic  of  typhoid  fever. 

Nervous  System. — Headache  is  one  of  the  most  important  and  con- 
stant of  the  earlier  symptoms  of  typhus  fever.  It  is  rarely  absent,  but  it 
differs  as  regards  severity  in  different  cases.  In  a  large  number  it  is 
moderate,  but  continuous  and  depressing.  In  a  few,  and  especially  among 
the  young,  it  is  agonising.  It  is  most  commonly  frontal,  but  it  may 
be  temporal,  occipital,  or  referred  to  the  whole  cranial  region.  The 
patient's  facial  expression  often  bears  testimony  to  the  severity  of  the 
headache,  in  the  wrinkled  brows  and  the  extreme  sensitiveness  to  light  or 
noise.  Giddiness  is  a  common  accompaniment  of  the  headache,  and  is 
especially  felt  in  sitting  up.  Pains  in  the  back  and  limbs,  and  a  sense  of 
weariness,  are  often  among  the  early  symptoms.  About  the  end  of  the  first 
week,  the  patient's  nervous  symptoms  undergo  a  change.  He  complains 
less  of  headache,  and  becomes  dull,  apathetic,  and  drowsy.  His  intelligence 
is  blunted,  and  he  is  slow  in  comprehending  and  in  responding  to  ques- 
tions, his  answers  being  at  the  same  time  confused.  His  memory,  too,  is 
impaired,  and  he  may  not  be  able  to  remember  anything  about  his  illness, 


108  GENERAL  DISEASES. 

or  to  tell  where  he  is.  He  is  less  alive  to  his  wants,  and  seems  to  prefer 
to  be  left  undisturbed.  During  the  night  he  is  wakeful  and  more  or  less 
delirious.  It  is,  however,  mostly  during  the  course  of  the  second  week 
that  the  characteristic  nervous  symptoms  of  typhus  become  prominent. 
There  is  now  delirium  both  by  day  and  night,  although  its  degree  varies 
greatly,  much  depending  upon  the  severity  of  the  case,  as  well  as  upon  the 
patient's  temperament,  habits,  and  occupation.  Sometimes  it  is  of  a  quiet 
muttering  and  not  unhappy  form ;  at  others,  busy  and  talkative,  not  unlike 
delirium  tremens.  Occasionally  it  is  wild  and  maniacal  (delirium  ferox) ; 
and  in  this  condition,  which  is  one  of  grave  danger,  errors  in  diagnosis  have 
sometimes  been  committed.  Deep  coma,  also  a  symptom  of  gravity,  may 
occur  in  the  course  of  the  second  week,  as  may  also  the  state  of  coma  vigil, 
described  by  Sir  William  Jenner,  in  which  the  patient,  although  quite 
insensible,  lies  with  his  eyes  widely  open,  with  pale  face,  clammy  skin, 
rapid  and  feeble  breathing,  and  an  almost  imperceptible  pulse.  This  con- 
dition is  said  to  be  invariably  fatal,  yet  it  must  be  admitted  that  cases  do 
occur  in  which  many  of  these  symptoms  present  themselves,  and  where, 
notwithstanding,  recovery  takes  place. 

The  effects  of  typhus  fever  upon  the  nervous  system  are  further  illus- 
trated by  the  patient's  extreme  prostration,  as  shown  by  the  low  dorsal 
decubitus,  the  trembling  of  the  muscles  and  subsultus  tendinum,  which  are 
seen  as  the  disease  advances  in  the  second  week,  as  also  by  retention  or 
incontinence  of  urine  or  faeces. 

Various  other  nervous  symptoms  are  of  occasional  but  rare  occurrence, 
such  as  convulsions,  muscular  rigidity,  and  cutaneous  anaesthesia  or  hyper- 
esthesia. Cerebral  meningitis  is  sometimes  met  wTith  in  typhus  fever,  and 
has  been  a  prominent  feature  in  some  of  the  recorded  epidemics. 

The  organs  of  special  sense  rarely  suffer  to  any  serious  extent.  The 
condition  of  the  pupils  has  already  been  referred  to.  They  are  contracted 
during  the  greater  part  of  the  fever,  and  they  may  also  be  unequal.  In 
profound  coma  the  pupils  may  present  the  pin-hole  appearance  described 
by  Graves,  but,  on  the  other  hand,  dilatation  of  the  pupil  has  occasionally 
been  observed  in  this  condition.  The  hearing  is  impaired  after  the  first 
few  days,  and  this  may  continue  on  to  the  convalescence,  when  it  gradually 
passes  off.  Although  it  has  been  stated  to  be  a  rather  favourable 
symptom,  it  is  only  relatively  so,  and  would  really  seem  to  have  little 
prognostic  significance.  Otitis  media  may  occasionally  be  met  with  in 
this  fever. 

Sequelae. — Numerous  sequelae,  more  or  less  common  to  all  forms  of 
blood  poisoning,  are  to  be  met  with  in  typhus  fever.  Among  these  may 
be  mentioned  pneumonia,  pleurisy,  and  empyema,  pyaemia,  noma,  boils, 
abscesses,  and  tuberculosis.  Only  the  more  important  and  characteristic 
will  be  referred  to. 

Swelled  leg  is  an  occasional  sequel  of  typhus,  generally  occurring  in  the 
convalescence  while  the  patient  is  still  in  bed.  It  is  preceded  by  pain  in 
the  calf  of  the  leg,  usually  the  left  leg,  which  soon  becomes  swollen  and 
stiff,  and  the  whole  limb  attains  an  enormous  size,  and  is  pale  and  glazed- 
looking.  It  is  due  in  most  cases  to  thrombosis  affecting  the  femoral  vein, 
which  may  be  felt  to  be  hard  and  painful;  but  it  would  seem  in  some 
instances  to  depend  upon  an  obstructed  condition  of  the  lymphatics  or  to 
inflammation  of  the  areolar  tissue.  It  is  not  generally  attended  by  much 
constitutional  disturbance,  and  it  tends  to  pass  off  completely  in  the  course 
of  a  few  weeks.     In  some  cases,  however,  the  limb  may  long  continue  to 


TYPHUS  FEVER.  109 

feel  weak,  and  its  veins  become  varicose.  Arterial  thrombosis  leading  to 
gangrene  is  very  rare. 

Glandular  swellings  and  affections  of  the  skin. — Inflammatory  swellings 
of  the  parotid  and  submaxillary  glands  occasionally  occur  about  the  time  of 
the  crisis,  or  in  convalescence.  They  usually  affect  one  side  of  the  face, 
but  may  involve  both.  The  swelling  forms  rapidly,  and  may  attain  to  a 
large  size,  causing  pain  and  discomfort  in  attempting  to  open  the  mouth. 
There  is  much  constitutional  disturbance  and  prostration.  Not  infre- 
quently suppuration  takes  place  and  an  abscess  forms,  but,  on  the  other 
hand,  the  swelling  may  disappear  spontaneously.  Similar  swellings  may 
occur  in  the  inguinal  and  other  glands,  forming  buboes  ;  or,  again,  there  may 
be  cellular  tissue  abscesses  in  various  parts  of  the  skin.  These  glandular 
affections  have  suggested  the  strong  resemblance  of  typhus  fever  to 
bubonic  plague,  and  Murchison  seemed  to  regard  the  two  diseases  as 
probably  identical — a  view,  however,  which  can  hardly  be  maintained  at  the 
present  day. 

Nervous  sequelce. — Certain  forms  of  paralysis  may  sometimes  be  met 
with  in  the  convalescence  from  typhus.  Of  these  the  most  frequent  is 
hemiplegia,  with  or  without  aphasia.  The  lower  extremities  may  be  para- 
lysed, and  present  some  of  the  symptoms  of  a  peripheral  neuritis.  In  most 
cases  the  paralysis  passes  off,  but  in  a  few  it  remains  permanently. 

Affections  of  the  mind  may  show  themselves  after  the  febrile  symptoms 
have  passed  off,  usually  in  the  way  of  mental  weakness  and  loss  of  memory, 
imbecility,  melancholia,  or,  in  rare  instances,  sudden  maniacal  attacks.  In 
these  mental  sequelae  of  typhus  the  prognosis  is,  as  a  rule,  good. 

Varieties  of  typhus  fever. — Numerous  varieties  have  been 
described,  but  it  is  seldom  possible  to  draw  sharp  distinctions,  except  to 
the  extent  that  in  some  cases  certain  of  the  features  of  this  fever  assume  a 
more  marked  prominence  than  in  others. 

The  following  are  among  the  varieties  described  by  Barrallier,  Murchi- 
son, and  other  authorities : — 

Inflammatory  typhus,  in  which  there  is  high  fever,  flushing  of  the  skin, 
severe  headache,  and  acute  delirium.  Such  cases  occur  mostly  in  the 
young  and  robust,  and  in  persons  of  the  upper  class. 

Nervous  or  ataxic  typhus  (brain  fever). — Cases  in  which  the  nervous 
symptoms  of  delirium,  somnolence,  tremor,  etc.,  predominate,  and  the  rash 
is  usually  dark  and  petechial. 

Adynamic  typhus. — Marked  by  great  physical  prostration,  involuntary 
evacuation,  and  tendency  to  collapse. 

Ataxo-adynamic  typhus. — A  combination  of  the  two  latter  varieties ; 
by  far  the  most  common  form. 

Typhus  siderans. — A  very  severe  and  rapidly  fatal  form. 

Typhus  levissimus. — Where  all  the  symptoms  are  of  the  mildest. 

Catarrhal  typhus. — So  called  from  its  frequent  complication  with 
bronchial  and  other  chest  symptoms.  This  form  has  been  specially  observed 
in  Ireland. 

ScorbiTtic  typhus. — A  grave  form,  in  which  haemorrhages,  both  sub- 
cutaneous and  internal,  occur  along  with  the  fever.  Some  epidemics  have 
been  characterised  by  the  prevalence  of  this  form. 

Diagnosis. — During  the  existence  of  an  epidemic  this  is  not  difficult. 
When,  however,  there  is  no  typhus  in  the  neighbourhood,  a  first  case  may 
give  considerable  trouble,  if  it  is  not  well  marked.  In  children  also,  even 
where   there  is  a  history  of  exposure,  it  may   be  difficult  to   come   to 


no  GENERAL  DISEASES. 

a  conclusion.     The  following  are  the  chief  points  to  which  attention  should 
be  directed : — 

The  patient's  general  appearance  and  his  mental  condition  are  of 
importance.  A  flushed  face  with  a  "  drunken "  expression,  and  pink 
ferrety  eyes,  are  suggestive  of  typhus.  If  added  to  this  there  is  mental 
confusion  and  deafness,  the  presumption  is  strengthened.  The  presence  of 
the  rash  is  of  course  final,  if  it  is  well  developed,  but  unfortunately  it  is 
occasionally  absent  altogether  (especially  in  children),  or  may  consist 
merely  of  the  faint  subcuticular  mottling,  which  it  requires  a  little  practice 
to  recognise.  It  should  be  looked  for  in  the  axillae  and  groins,  and  is 
best  seen  in  the  shadow  of  the  bedclothes,  being  often  imperceptible  in  a 
strong  light.  Flea-bites  may  cause  difficulty,  but  may  be  distinguished 
from  typhus  petechias  by  their  well-defined  outline  as  well  as  by  the  tiny 
puncture  in  their  centre.  To  those  who  have  had  previous  experience  of 
the  fever,  its  characteristic  odour,  if  present,  will  give  great  assistance  in 
diagnosis. 

In  coming  to  a  conclusion,  all  other  possibilities  should  be  carefully 
excluded.  The  lungs,  especially  their  apices,  should  be  examined  for 
pneumonia,  as  a  typhoid  condition  in  that  disease  may  readily  be  mistaken 
for  typhus.     The  other  diseases  to  be  differentiated  are  the  following : — 

Typhoid  fever. — A  full  account  of  the  differential  diagnosis  of  this 
fever  from  typhus  will  be  found  in  the  article  headed  "  Typhoid  Fever." 

Purpura.  —  The  skin  condition  has  been  mistaken  for  a  typhus 
eruption,  but  the  haemorrhages  are,  as  a  rule,  larger  than  in  typhus,  and 
there  is  no  subjacent  rash.  Moreover,  it  is  exceptional  to  find  purpura 
associated  with  an  elevated  temperature,  while  the  haemorrhages  from  the 
mucous  membranes  so  characteristic  of  this  disease  are  rarely  found  in 
typhus.  It  is,  however,  to  be  remembered  that  there  is  a  scorbutic  or 
purpuric  form  of  typhus. 

Meningitis. — The  absence  of  a  rash  is  the  chief  distinction.  Again, 
in  meningitis  the  senses  are  at  first  preternaturally  acute,  whereas  in 
typhus  they  are  dulled.  The  typhus  patient,  therefore,  is  not  nearly  so 
irritable,  nor  is  he  so  liable  to  utter  the  cerebral  cry  so  characteristic  of 
children  with  meningitis.  On  the  other  hand,  it  must  be  admitted  that 
squint,  ptosis,  inequality  of  the  pupils,  and  the  like,  though  more  frequent 
in  meningitis,  have  all  been  noticed  in  uncomplicated  typhus.  The  tache 
cerebrate  may  be  of  some  assistance  in  making  the  diagnosis  in  favour  of 
the  brain  condition. 

Urcemia  has  been  frequently  confused  with  typhus,  especially  when 
supervening  suddenly  in  a  chronic  kidney  condition.  The  absence  of  rash 
and  pyrexia  should  clear  up  the  case,  but  it  is  as  well  during  a  typhus 
epidemic  to  remember  that  the  mistake  has  been  made. 

Measles. — A  fading  measles  rash  occasionally  very  closely  resembles 
that  of  typhus.  The  history  of  catarrh  and  of  a  profuse  rash  on  the  face 
will  decide  the  diagnosis  in  favour  of  measles.  The  typhus  rash  does  not 
usually  invade  the  face  to  any  marked  extent,  though  it  occasionally 
appears  over  the  angles  of  the  jaws.  When  the  measles  rash  is  well  out 
on  the  body,  and  has  not  begun  to  fade,  there  should  be  no  difficulty,  the 
spots  being  more  raised  and  larger  than  in  typhus,  while  they  are,  more- 
over, often  arranged  in  crescents. 

Prognosis. — It  may  be  broadly  stated  that  the  older  the  patient  is 
the  worse  is  his  chance  of  recovery.  The  death  rate  varies  considerably, 
but  in  many  epidemics,  when  all  cases,  including  children,  are  reckoned,  it 


TYPHUS  FEVER.  in 

is  probably  not  much  more  than  10  per  cent.  If,  however,  only  patients 
of  over  thirty  years  of  age  were  counted,  this  rate  would  be  probably  at 
least  trebled. 

Any  condition  which  has  lowered  the  resisting  power,  or  has  impaired 
the  organs  of  elimination,  makes  the  prognosis  very  grave.  Thus  over- 
work, especially  mental  overwork,  increases  the  chance  of  a  fatal  termina- 
tion. Alcoholism,  above  all,  when  it  has  permanently  damaged  the 
kidneys,  gives  the  case  an  unfavourable  bias.  As  regards  symptoms 
arising  in  the  course  of  the  fever,  which  are  of  grave  import,  great 
nervous  prostration  in  the  early  days  of  the  disease  is  a  very  bad  sign. 
The  same  may  be  said  of  delirium  ferox,  which  is  very  exhausting  to  the 
patient.  Coma  occurring  at  any  time  is  serious.  A  temperature  rising 
rather  than  falling  after  the  twelfth  day  is  dangerous,  and  if  about  the 
fourteenth  day  it  shows  signs  of  rising  above  106°,  it  is  exceedingly 
probable  that  a  fatal  hyperpyrexia  will  terminate  the  case.  Other  very 
grave  signs  are  flapping  of  the  alse  nasi,  hypostatic  staining  of  the  skin  of 
the  back,  incontinence  or  retention  of  urine,  and  eyes  with  pin-hole  pupils. 
Children,  as  a  rule,  go  through  the  fever  very  well.  On  the  other  hand, 
heavy,  fat  persons,  and  very  muscular  and  powerful  men,  often  succumb. 

Treatment. — Bearing  in  mind  the  fact  that  typhus  is  due  originally 
to  want  of  sufficient  ventilation,  it  seems  only  reasonable  to  suppose  that 
cases  should  benefit  if  nursed  in  large  and  airy  rooms.  In  the  plans  of  the 
new  fever  hospital  for  Edinburgh  this  has  been  recognised,  and  allowance 
is  made  for  3000  cubic  feet  of  air  per  patient,  a  considerably  larger  figure 
than  that  suggested  for  the  other  wards.  If  this  space  cannot  be  provided, 
care  should  be  taken  to  secure  very  frequent  renewal  of  air,  and  indeed 
cases  seem  to  do  very  well  in  what  might  be  described  as  a  draught. 
While  the  temperature  remains  high,  the  bedclothes  should  be  very  light, 
a  single  sheet  and  blanket  being  quite  sufficient.  After  the  crisis,  however, 
it  is  advisable  to  move  the  patients  to  a  convalescent  ward  kept  at  a 
warmer  temperature,  and  to  add  an  extra  blanket  to  their  coverings. 

Typhus  fever  requires  skilled  nursing,  and  if  a  nurse  who  has  had 
experience  of  it  cannot  be  procured,  it  is  well  to  get  one  who  has  at  least 
had  experience  of  nursing  cases  of  typhoid  fever.  The  patient's  mouth 
should  be  most  carefully  attended  to,  and  cleansed  several  times  a  day,  the 
sordes  being  removed  from  the  teeth  and  the  tongue  scrubbed  and 
anointed  with  some  antiseptic  ointment,  boric  acid  and  vaseline  being  a 
good  preparation.  The  patient  should  be  sponged  with  a  dilute  antiseptic 
at  least  twice  daily,  or  more  often  if  the  case  is  severe  and  the  odour  well 
marked.  In  the  Edinburgh  City  Hospital,  Jeyes'  fluid  is  used  for  this 
purpose  in  tepid  water.  Great  care  should  be  taken  to  see  that  the 
patient  has  an  opportunity  of  passing  water  frequently,  and  the  bladder 
must  be  regularly  percussed  to  see  that  no  accumulation  occurs.  The 
patient  should  be  abundantly  supplied  with  cold  water  to  drink.  If  he  is 
too  ill  to  ask  for  it,  it  should  be  forced  upon  him.  The  more  fluid  he 
takes  the  better  is  his  chance  of  eliminating  the  toxines  of  the  disease. 

As  regards  diet,  it  must  be  remembered  that  though  the  bowel  is 
not  ulcerated,  as  it  is  in  typhoid  fever,  still  the  high  temperature  renders 
the  digestion  exceedingly  weak.  The  food  must  be  fluid,  and  should 
consist  chiefly  of  measured  quantities,  say  3  oz.  of  milk  administered 
every  two  hours.  The  milk  should  not  be  allowed  to  stand  at  the  bedside, 
but  should  be  regarded  as  a  meal.  It  may  be  supplemented  by  beef- 
or  chicken-tea,  fluid   meat  extracts,  and  egg-flip.     After   the  crisis  the 


ii2  GENERAL  DISEASES. 

appetite  rapidly  returns,  and  this  dietary  may  be  increased  by  the  addition 
of  bread,  fish,  and  chicken. 

The  question  of  stimulation  is  always  important.  It  is  not  by  any 
means  necessary  to  give  alcohol  as  a  routine.  If,  however,  the  medical 
attendant  is  in  doubt,  it  is  safer  to  give  it.  Beef-tea  will  in  many  cases 
be  quite  sufficient  to  stimulate  the  patient.  It  must  be  confessed,  however, 
that  the  majority  of  patients  require  alcohol  at  the  time  of  the  crisis,  if 
they  have  not  done  so  earlier.  If,  as  happens  especially  in  alcoholic  cases, 
the  stimulant  fails  to  improve  the  pulse  sufficiently,  cardiac  tonics,  such  as 
digitalis  or  strophanthus,  may  be  of  service.  In  cases  where  there  is 
no  diarrhoea,  and  where  there  is  no  subsultus,  strychnine  may  be  used  with 
advantage.  We  may  add  here,  that  if  alcohol  is  given,  it  must  be  given 
cautiously  at  first  and  in  measured  quantities. 

Sleeplessness  and  excitement  must  be  treated  by  suitable  hypnotics. 
Beef-tea  given  hot  is  sometimes  quite  sufficient.  If  it  is  not,  sulphonal,  or, 
when  the  pulse  is  very  bad,  paraldehyde  gives  good  results.  If  a  hypnotic  is 
given,  it  should  be  persevered  with,  and  a  second  dose  should  be  ordered  if 
the  patient  is  not  asleep  within  the  time  the  medicine  might  reasonably 
be  expected  to  act. 

Constipation  and  diarrhoea  may  both  give  trouble.  For  the  former  it 
is  as  well  to  remember  that  too  large  a  close  of  aperient  medicine  may 
cause  a  troublesome  attack  of  the  latter.  Enemata  are  therefore  to 
be  preferred,  or  very  small,  say  1-drm.,  doses  of  castor-oil.  For  diarrhoea, 
it  is  first  necessary  to  stop  the  beef-tea  or  any  meat  preparation  which 
the  patient  is  taking,  and  either  to  boil  the  milk  or  dilute  it  with  lime- 
water.     Occasionally  an  astringent  may  be  required. 

Headache  is  often  a  distressing  symptom.  A  5-gr.  powder  of 
citrate  of  caffeine  may  relieve  it,  and  is  preferable  to  any  drug  of 
the  phenazone  group.  Evaporating  lotions  or  ice  to  the  head  may  also  be 
of  assistance. 

For  coma,  strong  coffee  has  been  recommended.  Blisters  have  also 
been  used,  but  they  are  not  without  disadvantages.  However,  in  desperate 
cases  their  use  is  quite  justifiable. 

If  there  is  retention  of  urine,  the  water  should  be  drawn  off  regularly 
with  a  catheter. 

Prophylaxis. — The  pulling  down  of  old  houses,  the  opening  up  of 
slums,  and  the  prohibition  of  one-roomed  dwellings,  are  the  most  rational 
measures  for  preventing  the  outbreak  of  typhus.  If  the  outbreak  has 
occurred,  the  compulsory  isolation  in  hospital  of  the  sufferers,  and 
quarantine  of  those  exposed,  will  do  much  to  stamp  it  out.  In  hospital, 
airy  wards  and  strict  attention  to  personal  hygiene  on  the  part  of  nurses 
and  doctors,  reduce  the  danger  to  a  minimum. 

The  typhus  patient  is  free  from  infection  five  weeks  from  the  onset  of 
the  disease.  His  clothes,  if  not  destroyed,  should  be  carefully  disinfected 
by  steam  before  he  is  allowed  to  leave  hospital. 

J.  0.  AFFLECK.         ■ 
CLAUDE  B.  KER.      I 


RELAPSING  FEVER.  113 


EELAPSING  FEVEE. 


Syn.,  Famine  Fever  ;  Spirillum  Fever  (Fr.,  Fievre  a  rechute ;  Typhus 
recurrent;  Ger.,  Armentyjohus). 

An  acute  infectious  fever,  characterised  by  the  presence  of  a  spiral 
micro-organism  in  the  blood,  by  a  rapid  onset  and  defervescence,  and  by  a 
repetition  of  the  fever  after  a  week's  apyrexia. 

History. — Eelapsing  fever  was  first  accurately  described  by  Eutty  as 
occurring  in  Dublin  in  1739.  There  is,  however,  little  doubt  that  it 
existed  previously,  and  indeed  Murchison  has  identified  it  with  a  disease 
mentioned  by  Hippocrates.  It  is  liable  to  occur  in  epidemics,  and  may 
not  appear  for  long  intervals.  Always  associated  with  periods  of 
famine,  it  is  most  likely  to  attack  those  suffering  from  hunger  and 
destitution.  It  has  most  frequently  been  observed  to  be  present  during 
epidemics  of  typhus,  and  no  doubt  this  fact  led  to  considerable  difficulty 
of  diagnosis  in  bygone  days.  While  it  has  appeared  in  the  British  Isles 
on  several  occasions  during  the  present  century — notably  in  1817-19,  in 
1826,  in  1843,  in  1847-48,  and  in  1868 — there  has  recently  been  so  little 
that  few  physicians  have  had  the  opportunity  of  observing  its  course. 
Its  prevalence  in  Ireland  during  the  famine  has  led  some  writers  to 
describe  it  as  a  disease  endemic  in  that  country,  but  Moore  conclusively 
proves  that  this  view  is  erroneous.  Eussia  has  had  frequent  epidemics, 
and  this  fever  was  one  of  the  hardships  which  the  French  army  had 
to  support  in  their  retreat  from  Moscow  in  1812.  In  India,  also,  during 
periods  of  famine,  the  disease  has  been  fairly  common,  but  in  many  of 
the  famine-stricken  districts  in  that  country  there  was  no  appearance  of 
it  in  1897.  The  last  time  the  fever  occurred  in  Edinburgh  was  in  the  year 
1870,  and  it  is  to  notes  of  this  epidemic  by  Muirhead,  by  whom  the  cases 
were  treated,  that  we  are  indebted  for  the  clinical  history  of  the  disease 
given  below. 

Eltiology. — Predisposing  causes. — Most  observers  agree  in  stating 
that  males  are  more  frequently  affected  than  females.  It  has  been 
suggested  that  this  is  due  to  the  fact  that  males  preponderate  in  the 
"  tramp  "  class,  which  seems  so  liable  to  the  disease.  As  regards  age,  it 
may  be  said  that  all  ages  are  attacked  indiscriminately. 

Famine,  as  has  been  mentioned  above,  is  undoubtedly  one  of  the  most 
important  of  the  predisposing  causes.  But  while  this  is  so,  it  is  interest- 
ing to  remark  that  in  the  last  outbreak  in  Edinburgh,  not  one  of  the 
individuals  attacked  could  be  said  to  be  underfed.  The  absence  of 
destitution,  therefore,  does  not  in  any  way  contradict  the  existence  of  the 
disease. 

Overcrowding  must  obviously  favour  the  propagation  of  any  contagious 
disease,  and  it  is  usual  to  find  that  the  majority  of  patients  suffering  from 
this  fever  have  been  living  crowded  together  and  with  very  insufficient 
air  space. 

Exciting  cause. — Obermeier,  in  1873,  discovered  in  the  blood  of 
relapsing  fever  patients  the  organism  which  bears  his  name — the  Spiro- 
chceta  Obermeieri.  This  is  a  spirillum,  and  consists  of  a  delicate  spiral 
filament  with  a  length  of  from  two  to  six  times  the  diameter  of  a  red  blood 
corpuscle.  From  experiments  on  monkeys,  it  has  been  established  that 
the  spirochete  is  really  the  cause  of  the  disease.  It  is  found  in  the  blood 
in  vast  numbers,  many  specimens  being  seen  in  a  microscopic  field.     It  is 

VOL.  I. 8 


ii4  GENERAL  DISEASES. 

freely  motile,  and  moves  rapidly  with  a  twisting  motion  across  the  field, 
displacing  the  blood  corpuscles  as  it  goes.  Even  under  a  low  power  this 
movement  of  the  corpuscles  may  be  noticed,  and  may  suggest  to  the 
trained  observer  the  presence  of  the  organism. 

The  spirillum  stains  well  with  Lomer's  methylene-blue.  It  has  not 
yet  been  cultivated  successfully  on  any  artificial  medium,  the  experiments 
on  animals  having  been  made  with  the  blood  of  patients.  It  lives, 
however,  outside  the  body,  and  may  be  kept  for  a  considerable  period  in 
sealed  tubes.  It  is  readily  killed  by  heat,  a  comparatively  low  tempera- 
ture being  quite  sufficient  to  destroy  it. 

During  the  course  of  the  disease  the  spirillum  is  found  in  the  blood 
till  the  time  of  the  crisis.  The  numbers  diminish  slightly  just  before  the 
crisis,  and  the  organism  cannot  be  found  when  the  temperature  has 
reached  the  normal.  During  the  apyrexial  period  it  is  absent,  but  returns 
again  with  the  second  attack  of  the  fever.  It  has  been  discovered  that,  on 
its  original  disappearance,  it  is  taken  up  by  the  spleen,  where  it  is  destroyed 
by  the  leucocytes.  Monkeys,  deprived  of  their  spleen  and  inoculated,  died, 
and  the  spirillum  was  found  after  death  in  the  general  circulation. 

Mode  of  infection. — Direct  contact  with  a  person  suffering  from 
the  disease  seems  to  be  the  most  common  method  of  spreading  it. 
Entering  a  badly  ventilated  room  occupied  by  a  patient,  is  quite  sufficient 
to  cause  the  fever.  It  would  seem,  therefore,  that,  as  in  typhus,  the  poison 
may  be  conveyed  through  the  air,  but  free  ventilation  renders  its  spread 
very  improbable.  The  great  incidence  of  the  disease  among  hospital 
laundry-women  makes  it  probable  that  fomites  can  convey  the  infection. 

Morbid  anatomy. — In  the  few  fatal  cases  which  have  been  recorded, 
no  characteristic  anatomical  changes  were  seen,  and  the  post-mortem  condi- 
tions are  only  those  resulting  from  pyrexia. 

Symptoms  and  course. — Incubation. — This  is  very  variable.  Oc- 
casionally a  few  hours  only  elapse  from  the  moment  of  infection  to  the 
appearance  of  the  fever.  On  the  other  hand,  fourteen  days  seems  to  be 
the  maximum  period.  On  an  average,  from  five  to  ten  days  appears  the 
most  likely  time. 

The  onset  of  relapsing  fever  is  invariably  sudden.  The  patient,  while 
at  his  ordinary  occupation,  may  be  seized  with  intense  headache,  giddiness, 
chilliness  or  rigors,  and  vomiting.  The  headache  is  usually  frontal,  and 
pains  in  the  limbs  and  back  are  common.  The  preliminary  chilliness,  or 
so-called  cold  stage,  is  succeeded  quickly  (within  a  few  hours)  by  a  feeling 
of  burning  heat,  and  the  temperature  is  found  to  be  considerably  elevated — 
104°  to  108°.     The  pulse  rate  runs  up  at  the  same  time. 

The  feeling  of  giddiness,  which  appears  to  be  a  characteristic  symptom 
of  the  fever,  makes  the  patient  take  to  his  bed  at  once.  Occasionally, 
even  at  this  early  period  delirium  may  set  in,  but  as  a  rule  this  symptom 
is  deferred  for  some  days.  The  tongue  is  usually  thickly  coated  with 
white  or  yellowish  fur,  and  in  most  cases  remains  moist  throughout  the 
illness.  Diarrhoea  at  this  stage  is  rare,  the  bowels  rather  inclining 
towards  constipation.  The  urine  is  high  coloured,  and  is  not  appreciably 
diminished  in  amount.  The  skin  is  usually  very  dry,  though  slight  sweats 
sometimes  occur  in  the  first  twenty -four  hours.  A  slight  icteric  tinge  of 
the  conjunctivae  is  usual,  and  in  some  instances  jaundice  is  very  marked. 
The  liver  and  spleen  are  both  enlarged,  and  are  tender  on  palpation. 

The  high  fever  persists  from  about  five  to  seven  days,  the  tempera- 
ture   varying    from    102°    to    108°    in   different   cases.      The    morning 


RELAPSING  FEVER. 


"5 


temperature  is  usually  lower  than  that  in  the  evening,  though  on  the  third 
day  the  evening  temperature  seems  to  have  a  tendency  to  be  lower,  being 
often  at  the  same  level,  and  rarely  higher  than  that  of  the  morning.  The 
pulse  is  in  most  cases  over  110,  quite  commonly  over  120,  and  in  bad  cases 
may  reach  a  higher  level.  During  the  course  of  the  fever  the  patient  is 
very-  restless  and  often  exceedingly  prostrate.  Thirst  is  intense,  and  is 
always  present.  Vomiting  is  a  frequent  symptom,  and  after  the  contents 
of  the  stomach  have  been  evacuated  there  is  great  retching  of  bilious 
material  and  occasionally  of  blood.  In  bad  cases  the  patient  may 
become  congested  or  livid  about  the  face. 

At  a  period  varying  from  the  fifth  to  the  seventh  day,  the  crisis  is 
ushered  in  by  slight  diarrhoea,  by  a  temporary  increase  in  the  temperature, 
and  occasionally  by  delirium.  The  fall  of  the  temperature  is  very 
remarkable,  the  sharpness  of  the  crisis  being  probably  unparalleled  in  any 
other  disease.  A  fall  of  10°  F.  in  twenty-four  hours  is  apparently 
common,  and    even    this  figure  has  been  exceeded.     The  temperature 


Day  of 
Disease 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

C. 

105° 
104 

r— i 

•41° 

1 

H 

\A 

A 

r 

I 

■40° 

. 

f 

\ 

103° 
102° 
101° 
100° 

99 
98 

V 

39° 

I 

38° 

V 

-37° 

97° 

36° 

/ 

96 
95° 

/ 

f 

4 

35° 

If 

94 

. 

Fig.  5. — A  case  of  relapsing  fever. — After  Muirhead. 

usually  falls  far  below  normal,  and  in  one  of  Muirhead's  cases  registered 
92° — a  somewhat  alarming  level.  Coincident  with  this  fall  of  temperature 
is  a  very  profuse  perspiration,  and  as  a  consequence  the  urine  at  this 
period  is  greatly  diminished  in  amount. 

After  this  brief  period  of  pyrexia,  which  may  be  described  as  the  first 
paroxysm,  the  patient  enters  the  first  period  of  apyrexia.  His  temperature, 
remaining  at  first  subnormal,  gradually  resumes  the  normal  level.  His 
tongue  is  clean,  his  appetite  is  good.  He  has  quite  lost  the  feelings  of 
giddiness  and  of  prostration  which  originally  compelled  him  to  take  to  his 
bed,  and  about  four  or  five  days  after  the  crisis  it  may  be  difficult  to 
dissuade  him  from  walking  home  from  the  hospital,  a  feat  which  he 
is  perfectly  capable  physically  of  performing.  But  about  fourteen  days 
after  the  time  he  was  originally  taken  ill,  and  from  seven  to  nine  days 
after  the  crisis,  he  is  suddenly  seized  again  with  similar  symptoms,  and 
enters  the  stage  of  the  first  relapse. 

The  first  relapse  has  rarely  any  premonitory  symptoms.  Occasionally 
a  slight  feeling  of  malaise  may  precede  it,  but  the  temperature  usually 


n6  GENERAL  DISEASES 

rises  suddenly,  at  least  3°  F.,  and  the  patient  suffers  from  shivering  or 
rigors,  as  in  the  first  paroxysm.  The  symptoms  are  merely  a  repetition  of 
the  original  attack.  Occasionally  the  relapse  is  more  severe ;  usually  it 
is  milder,  or  of  equal  severity.  Vomiting,  jaundice,  diarrhoea,  may  all  be 
troublesome.  The  usual  point  of  difference  is  that  the  relapse  seldom  lasts 
so  long  as  the  first  paroxysm.  It  varies  in  duration  from  three  to  five 
days  as  an  average,  although  longer  and  shorter  periods  have  been  recorded. 

During  the  first  paroxysm  the  urine  voided  is  in  amount  about  the 
same  as  in  health,  but  during  the  relapse  its  amount  is  considerably 
increased.  This  increase  is  to  be  particularly  remarked  just  before  the 
crisis,  when  some  of  Muirhead's  cases  passed  6  or  7  oz.  every  hour,  and 
one  case  passed  84  oz.  in  the  day. 

The  second  crisis  is  in  every  way  comparable  to  the  first.  The 
temperature  usually  reaches  its  acme  just  before  its  occurrence,  and  then 
falls  suddenly  and  with  great  rapidity  to  some  degrees  below  normal. 
Sweating,  which  has  been  already  said  to  be  a  feature  of  the  first  crisis, 
is  still  more  markedly  a  concomitant  of  the  second,  and  sudaminal 
rashes  are  frequent  at  this  period.  Prostration  is  also  a  well-marked 
symptom,  as  is  only  to  be  expected  after  such  a  depression  of  temperature. 
The  amount  of  urine  is  now  naturally  decreased. 

The  patient  now  enters  the  second  period  of  apyrexia,  which  may  in 
most  cases  be  said  to  be  coincident  with  the  stage  of  convalescence.  But  in 
some  patients  a  second  relapse  may  occur,  appearing  usually  about  the 
twenty-first  day  from  the  commencement  of  the  first  paroxysm.  This 
rarely  lasts  more  than  three  days,  and  is  ordinarily  of  a  milder  character 
than  the  previous  attacks.  In  rare  instances  third  and  fourth  relapses 
have  been  reported. 

Convalescence  is  not  so  rapid  as  in  typhus,  and  indeed  may  be  said  to 
be  protracted  and  apt  to  be  interfered  with  by  the  occurrence  of  various 
sequelae. 

Analysis  of  symptoms  and  complications. — Alimentary  System. — 
The  tongue  is  always  coated,  the  fur  being  yellowish  or  grey.  It 
is,  however,  usually  moist.  In  severe  cases  it  may  become  dry  or  brown 
Thirst  is  constant.  Vomiting  is  nearly  always  present,  and  may  be 
dangerous.  Nausea,  without  vomiting,  may  occur.  The  appetite  is  lost 
in  the  first  paroxysm,  but  is  particularly  good  in  the  first  apyrexial 
period,  and  may  last  through  the  first  relapse.  The  bowels  are,  as  a  rule, 
confined,  though  diarrhoea  may  precede  the  crisis. 

The  chief  complications  referable  to  this  system  are  pharyngitis, 
dangerous  vomiting,  severe  diarrhoea,  or  dysentery. 

Circulatory  and  Hemopoietic  System.  —  The  pulse  is  increased  in 
rapidity,  varying  as  a  rule  from  110  to  130  beats  per  minute,  and  rising 
and  falling  with  the  variations  of  temperature.  It  may  become  excessively 
rare  after  the  crisis.  In  bad  cases  it  may  reach  160  or  more.  It  is 
usually  full  during  the  paroxysms,  and  may  become  very  dicrotic  during 
the  periods  of  apyrexia.     The  first  sound  of  the  heart  is  weakened. 

The  spleen  is  invariably  enlarged,  and  this  enlargement  may  persist 
into  convalescence.  As  a  rule,  however,  its  size  is  decreased  during  the 
apyrexial  period,  and  the  organ  becomes  enlarged  again  with  the  onset  of 
the  relapse. 

In  old  and  feeble  patients  the  complication  to  be  dreaded  is  heart 
failure,  to  which  cause  most  of  the  deaths  are  due. 

Respiratory   System. — Bronchitis   is   not   uncommon,  and  occasionally 


RELAPSING  FEVER.  117 

pneumonia  may  complicate  the  fever.     (Edema  glottidis  and  laryngitis  are 
also  met  with. 

Genito -urinary  System.  —  The  variations  in  the  quantity  of  urine 
passed  have  been  alluded  to  above.  Albumin  is  present  in  small  amount 
in  about  one-fourth  of  the  cases.     Chlorides  are  diminished. 

Abortion  of  pregnant  women  is  almost  invariable,  and  usually  occurs 
during  the  relapse. 

Nervous  System.  —  Headache  is  very  common,  and  may  be  very 
severe.  Giddiness  is  practically  constant.  All  patients  are  restless  and 
uneasy.  Insomnia  is  also  common,  and  is  sometimes  due  to  intense 
neuralgic  pains,  usually  limited  to  the  larger  nerves.  Delirium  may  last 
throughout  the  fever,  but  is  generally  not  seen  till  just  before  the  crisis, 
and  it  often  is  absent  altogether. 

Integumentary  System. — The  skin  is  always  yellow,  and  jaundice  may 
in  some  cases  be  very  well  marked.  Just  before  the  crisis  the  face  is  apt 
to  become  congested  and  purple.  The  skin  is  pungently  hot  and  very  dry, 
and  is  said  to  have  a  characteristic  and  unpleasant  odour.  Eruptions, 
resembling  that  of  enteric  fever,  are  occasionally  but  rarely  met  with. 
Petechise  and  small  haemorrhages  into  the  skin  are  sometimes  observed. 
In  connection  with  this,  we  may  mention  that  epistaxis  is  not  an 
uncommon  complication.  The  profuse  sweatings  and  sudaminal  rashes 
occurring  at  the  periods  of  crisis  have  been  already  alluded  to. 

Sequelae. — The  most  important  of  these  is  ophthalmia,  which  seems 
very  liable  to  supervene  in  convalescence.  Glandular  enlargements  in  the 
groin,  neck,  and  parotid  also  occur.  OEdema  of  the  lower  limbs  is  not 
infrequently  noticed,  and  amongst  other  sequelae  may  be  mentioned  slight 
paralysis  and  otorrhcea. 

Diagnosis. — The  detection  of  the  spirillum  under  the  microscope  is 
the  best  and  surest  method  of  diagnosis,  but  in  default  of  this  it  will 
depend  chiefly  on  the  existence  of  an  epidemic,  on  a  sudden  onset  of  high 
fever,  with  giddiness,  slight  jaundice,  and  vomiting,  and  on  the  marked 
crisis,  with  subnormal  temperature  about  the  seventh  day.  The  conditions 
with  which  the  fever  is  likely  to  be  confused  are  influenza,  typhus,  and 
malaria.    The  occurrence  of  the  relapse  will  probably  clear  up  any  difficulty. 

Prognosis  is  always  good  except  in  old  persons  or  complicated  cases 
The  death  rate  is  usually  below  6  per  cent.  Severe  diarrhoea,  extreme 
jaundice,  and  excessive  prostration  are  the  symptoms  which  will  give 
reason  for  most  alarm. 

Treatment. — There  is  no  specific  treatment  for  the  disease.  It 
is  advisable  to  merely  support  the  patient's  strength  and  treat  complica- 
tions as  they  arise.  A  tonic  treatment  of  strychnine  or  mix  vomica 
seems  to  give  good  results.  Sleeplessness  may  have  to  be  combated,  as 
may  also  vomiting  and  diarrhoea.  If  the  temperature  is  over  106°  F.,  cold 
packing  may  be  resorted  to. 

Many  drugs  have  been  tried  to  prevent  the  occurrence  of  the  relapse. 
Quinine  appears  to  exercise  no  favourable  action.  Experiments  with 
sero-therapy  have  been  made  in  Eussia,  but  in  the  meantime  their  success 
is  doubtful,  and  we  must  be  content  to  adopt  an  expectant  treatment  and 
see  that  the  patient  is  properly  nursed. 

J.  0.  AFFLECK. 
CLAUDE  B.  KEE. 


n8  GENERAL  DISEASES. 


TYPHOID  FEVER 


Syn.,  Enteric  Fever;  Bilious  Eemittent  Fever;  Infantile  Eemittent 
Fever;  Pythogenic  Fever.  Fr.,  Dothtin-enUrie ;  Fxevre  typhoide ; 
Fievre  gastriqae ;  Ger.,  Abdominaltyphus. 

An  infectious  fever  of  about  four  weeks'  duration,  characterised' by  a 
peculiar  course  of  the  temperature,  especially  in  its  early  stage;  by  a 
lesion  of  the  bowels,  accompanied  in  general  with  abdominal  tenderness 
and  diarrhoea  ;  by  the  appearance  of  a  rose-coloured  eruption  on  the  skin ; 
and  by  great  prostration  of  strength. 

History. — The  full  identification  of  this  fever  belongs  to  the  nine- 
teenth century.  Prior  to  this,  symptoms  corresponding  to  those  of  typhoid 
fever  had  been  described,  and  even  the  intestinal  lesions  noticed  by  many 
writers,  especially  by  Spigelius,  Panardius,  Willis,  Sydenham,  Baglivi,  and 
Hoffmann,  in  the  seventeenth  century ;  and  by  Lancisi,  Manningham,  Hux- 
ham,  Morgagni,  Andral,  and  many  others  in  the  eighteenth  century;  but  it  is 
clear  no  sharp  distinction  was  drawn  between  cases  presenting  these  char- 
acters and  others  of  the  fevers  which  prevailed  more  or  less  in  these  times. 

A  most  important  advance  towards  a  knowledge  of  this  disease  was 
made  when,  in  1818,  Bretonneau  of  Tours  recognised  the  connection 
between  certain  febrile  symptoms  and  the  existence  of  lesions  in  the 
solitary  and  agminate  glands  in  the  ileum.  Regarding  these  as  of  in- 
flammatory character,  he  named  the  disease  dothtin-cnUrite  or  dothUn- 
enterie.  Louis,  in  1829,  published  his  celebrated  work  on  this  malady, 
which  gave  the  most  complete  account  of  it  that  had  hitherto  appeared, 
and  he  it  was  who  first  gave  it  the  name  of  fievre  typhoide. 

Notwithstanding  these  observations,  there  still  existed  much  confusion 
and  uncertainty  respecting  the  relation  of  this  to  other  fevers,  especially  to 
typhus.  Thus  in  France,  where  the  subject  of  typhoid  fever  was  most 
thoroughly  investigated,  and  where  indeed  the  disease  appears  to  have 
widely  prevailed  during  many  years,  there  would  seem  to  have  been  no 
attempt  made  to  discriminate  between  this  and  others  of  the  continued 
fevers.  In  England,  again,  where,  notwithstanding  cases  and  even  epidemics 
of  what  in  all  likelihood  was  typhoid  fever  had  been  from  time  to  time 
recorded,  such  seem  to  have  been  regarded  merely  as  forms  of  typhus,  which 
was  the  infectious  fever  most  generally  met  with  and  described.  A  nearer 
approximation  to  a  precise  distinction  between  those  fevers  was  made  in 
Germany,  where  they  were  recognised  as  typhus  exanthematicus  and  typhus 
abdomincdis  respectively. 

The  advance  of  clinical  study  led  to  more  minute  observation  of  the 
symptoms  and  pathological  changes  attending  these  fevers,  and  their  non- 
identity  came  to  form  a  subject  for  discussion  among  physicians.  Gerhard 
and  Pennock  of  Philadelphia  in  1837,  Shattock  of  Boston  in  1839,  and 
A.  P.  Stewart  of  Glasgow  in  1840,  all  made  contributions  of  the  highest 
value  towards  making  clear  the  distinctions  between  typhus  and  typhoid 
fevers,  both  from  the  clinical  and  pathological  standpoint ;  and  the  matter 
was  finally  set  at  rest  by  the  celebrated  papers  of  Sir  William  Jenner, 
published  between  1849  and  1852. 

Etiology. — The  etiological  conditions  associated  with  typhoid  fever 
embrace  age,  sex,  climate,  season,  but  especially  infection  and  the  specific 
micro-organism  of  the  disease,  its  mode  of  propagation,  and  the  various 
ways  of  its  introduction  into  the  human  body. 


TYPHOID  FEVER.  119 

Predisposing  causes, — Age. — Typhoid  fever  is  a  disease  of  early  life. 
The  majority  of  cases  occur  between  the  ages  of  10  and  25.  It  is  frequently 
enough  seen  before  10,  but  it  is  not  recognised  as  a  disease  of  infancy, 
although  cases  are  recorded  of  its  occurrence  at  6  months,  and  even  in  the 
new-born.     It  is  exceptional  after  40  and  very  rare  after  60. 

Sex. — There  seems  almost  no  difference  between  the  liability  of  the  two 
sexes  to  typhoid  fever,  but  probably  a  slightly  greater  proportion  of  males 
are  affected. 

Climate. — Typhoid  fever  is  met  with  in  all  parts  of  the  world,  and  while 
at  one  time  it  was  regarded  as  more  liable  to  occur  in  temperate  climates, 
it  is  now  recognised  as  a  very  common  fever  of  tropical  countries,  although 
its  identification  is  liable  to  be  more  difficult  by  reason  of  its  resemblance 
to  other  febrile  disorders.  It  may  be  regarded  as  endemic  in  most  countries, 
with  a  liability  to  local  epidemic  outbreaks,  to  which  unfavourable  sanitary 
conditions  largely  contribute. 

Season. — Autumn  is  the  season  in  which  typhoid  fever  specially  pre- 
vails, the  rains  of  this  time  of  year  doubtless  favouring  the  passage  of  the 
poison  into  sources  of  drinking  water.  Hence  it  has  been  called  autumnal 
or  "  fall "  fever. 

Infection. — Long  after  the  distinctive  characters  of  typhoid  fever 
had  been  clearly  established,  the  nature  of  the  disease  poison  and  the 
conditions  of  its  propagation  continued  to  be  a  subject  of  inquiry,  and 
numerous  views  were  held  among  authorities.  Of  these  only  two  need  be 
here  referred  to — 

The  view  of  Murchison,  who  held  that  typhoid,  like  some  other  fevers, 
might  originate  de  novo,  if  certain  conditions  deemed  favourable  for 
its  development  were  present.  The  existence  of  decomposing  organic 
matter  and  its  access  to  drinking  water,  to  air,  etc.,  were  regarded  as  a 
sufficient  cause  for  an  outbreak  of  typhoid  in  the  individual  or  in  a 
community,  without  the  necessary  presence  of  a  previous  case.  Holding 
this  view,  Murchison  named  the  disease  pythogenic  fever  (wvdofjuou,  I  decay). 

The  view  of  Budd,  who  held  that  the  fever  was  specific  in  its  nature, 
and  could  arise  only  from  a  pre-existing  case.  This  latter  view  was  that 
which  gained  widest  acceptance,  and  the  vehicle  of  the  conveyance  of  the 
disease  was  recognised  as  being  the  intestinal  discharges. 

The  progress  of  sanitary  science,  and  the  bearing  of  the  germ  theory 
upon  the  nature  and  spread,  of  infections,  gave  a  special  direction  to  the 
inquiries  into  the  causes  of  typhoid  fever,  and  the  result  has  been  the 
discovery  of  the  specific  infecting  agent  in  this  disease. 

Bacteriology. — Eberth,  in  1880,  succeeded  in  finding  small  masses  of 
bacilli  in  the  Peyer's  patches,  mesenteric  glands,  spleen,  and  other  organs 
of  a  series  of  cases  which  had  died  of  typhoid  fever.  His  claim  that  these 
bacilli  were  the  cause  of  the  disease  was  supported  by  the  experiments  of 
Gaffky,  who  investigated  their  life  history,  and  succeeded  in  cultivating 
them  on  various  media.  Other  observers  have  caused  death  in  small 
animals  by  the  injection  of  pure  cultures  of  this  bacillus,  and  quite  recently 
Eemlinger  has  succeeded  in  producing  a  disease,  apparently  identical  with 
the  fever  as  it  occurs  in  man,  by  feeding  rabbits  on  lettuce  watered  with 
water  containing  the  bacillus.  Klein,  moreover,  has  found  this  bacillus  in 
drinking  water  during  epidemics,  and  at  present  the  evidence  is  distinctly 
in  favour  of  its  really  being  the  cause  of  the  disease. 

The  bacillus  of  Eberth  (Bacillus  typhosus)  is  a  short  thick  rod  with 
"rounded  extremities.     In  young  cultures,  however,  elongated  filamentous 


120  GENERAL  DISEASES. 

forms  are  frequently  seen.  It  is  actively  motile,  as  may  be  readily  de- 
monstrated by  the  examination  of  "  hanging-drop "  preparations.  It  is 
provided  with  numerous  flagella,  but  the  detection  of  these  requires 
special  methods  of  staining.  The  bacillus  itself  stains  well  with  carbolic, 
methylene-blue  or  gentian-violet. 

The  chief  difficulty  with  which  we  have  to  contend  when  endeavouring 
to  isolate  the  bacillus,  either  from  suspected  water  or  from  the  organs  of 
an  enteric  patient,  is  the  great  resemblance  which  it  bears  to  the  B.  coli 
communis.  The  fact  that  this  latter  micro-organism  is  normally  present  in 
the  intestine,  and  rapidly  multiplies  when  any  intestinal  disease  exists, 
makes  it  impossible  to  differentiate  the  two  germs  in  the  stools  by  direct 
examination,  and  it  is  necessary  to  make  use  of  cultures  on  various  media 
in  order  to  arrive  at  any  definite  conclusion.  Eberth's  bacillus  gives  a 
colourless  growth  on  potato,  it  does  not  liquefy  gelatin,  and  it  neither 
forms  indol  in  the  course  of  its  growth,  nor  curdles  milk.  The  B.  coli 
communis,  on  the  other  hand,  gives  a  brownish  scum  on  potato,  and, 
as  regards  the  other  points  mentioned,  produces  an  exactly  opposite  effect. 
Eecently  the  Widal  reaction  (to  be  alluded  to  later)  has  been  used  to 
distinguish  the  two  bacilli,  and  although  it  does  not  appear  to  be  absolutely 
reliable,  it  cannot  fail  to  be  of  great  service  in  making  this  differentiation. 

To  demonstrate  the  bacillus  in  the  tissues,  it  is  necessary  to  stain 
sections  of  the  spleen,  liver,  or  mesenteric  glands.  If  a  case  terminates 
fatally  in  the  early  days  of  the  disease,  the  bacilli  may  also  be  seen  in  the 
congested  Peyer's  patches,  but  once  necrosis  has  set  in  they  are  not  so  readily 
detected.  It  need  hardly  be  said  that  cultures  must  also  be  made,  as  the 
B.  coli  communis  has  been  found  in  all  the  situations  mentioned.  To  obtain 
cultures  the  spleen  is  usually  the  organ  selected,  as  Eberth's  bacillus 
abounds  there  in  well-marked  cases,  whereas  the  B.  coli  communis  is  not 
likely  to  be  present  in  such  large  numbers.  The  reverse  is  the  case  with 
the  stools,  from  which  it  is  very  difficult  to  get  pure  cultures  of  the  typhoid 
bacillus  except  during  the  first  week  of  the  fever. 

Cultures  of  the  pure  bacillus  may  be  made  on  agar,  gelatin,  or  bouillon. 
They  grow  quite  well  at  the  temperature  of  the  room,  but  if  a  young  and 
active  culture  is  desired  they  should  be  incubated  at  37°  C.  A  streak 
culture  on  agar  shows  a  bluish-grey  film  of  growth  with  no  special 
characteristics.     The  bouillon  culture  shows  a  uniform  turbidity. 

The  B.  coli  communis  appears  to  play  a  secondary  part  in  the  produc- 
tion of  the  disease.  It  has  recently  been  noted  by  various  observers,  that 
not  only  is  this  bacillus  more  virulent  when  obtained  from  a  case  of  typhoid 
fever,  but  that  the  virulence  of  Eberth's  bacillus  is  increased  in  the  presence 
of  the  coli  bacillus.  The  same  may  also  be  said  of  a  third  bacillus,  which 
has  marked  resemblances  to  the  two  mentioned  above,  the  B.  enteritidis  of 
Gartner.  We  must  await  further  experiments  before  the  exact  role  of 
these  three  organisms  in  the  causation  of  the  various  symptoms  of  typhoid 
fever  is  finally  determined. 

Vehicles  by  -which  the  bacillus  is  transmitted. —  Water. — The  fact 
that  the  poison  of  typhoid  fever  is  in  most  cases  carried  by  water  has 
been  long  recognised,  and  instances  of  epidemics  depending  on  a  faulty 
water  supply  are  only  too  common.  Eecently  the  detection  of  the  specific 
bacillus  in  suspected  water  has  completed  the  chain  of  evidence,  but, 
considering  the  great  difficulties  of  analysis,  it  would  be  at  present  prema- 
ture to  accept  a  water  as  safe,  merely  because  the  presence  of  the  typhoid 
germ  cannot  be  proved. 


TYPHOID  FEVER.  121 

The  following  are  fair  examples  of  epidemics,  depending  on  contaminated 
water : — 

In  the  winter  of  1896-97  an  outbreak  occurred  in  the  small  town  of 
Halstead,  in  the  county  of  Essex,  and  was  reported  by  Thresh.  On  17th 
November  1896,  a  man  suffering  from  typhoid  fever  was  admitted  to  an 
isolation  hospital,  standing  on  a  hill  on  the  outskirts  of  the  town.  The 
subsoil  water  of  this  hill  supplied  a  drinking  fountain  on  a  public  road, 
and  the  surplus  water  from  this  fountain  supplied  one  cottage  only.  On 
28th  December  a  workman  residing  in  this  cottage  was  attacked  by  the 
fever.  Shortly  afterwards,  four  children,  all  of  whom  acknowledged  drink- 
ing frequently  at  the  fountain,  developed  the  disease.  On  investigation, 
it  was  found  that  the  hospital  sewer  was  defective,  and  the  water  pipes 
passed  underneath  it.  It  appeared  that  after  heavy  rains  the  leaking 
sewage  was  washed  into  the  water  pipes,  which  were  of  rough  construction, 
and  so  contaminated  the  supply  of  the  fountain  and  of  the  infected  cottage. 
Water  collected  after  a  rainfall  was  found  to  be  turbid,  and  the  bacillus 
of  Eberth  was  successfully  cultivated  from  it. 

Maidstone  has  recently  suffered  from  an  epidemic,  no  less  than 
2000  persons  being  attacked  by  the  disease.  The  water  supply  was  un- 
doubtedly to  blame,  the  majority  of  the  patients  obtaining  their  water  from 
the  same  company.  The  bacteriological  investigations,  however,  have  un- 
fortunately not  been  very  successful,  and  have  given  rise  to  some  controversy. 

Milk. — Milk,  it  is  well  known,  is  very  readily  contaminated  by  germs, 
and  several  epidemics  in  this  country  have  been  traced  to  such  a  source. 
The  contamination  may  occur  from  infected  water  being  used  to  adulterate 
the  milk,  and  even  to  wash  the  milk  cans,  or  from  the  cows  being  milked 
by  some  person  who  is  at  the  same  time  nursing  a  case  of  typhoid  fever. 
Such  transmission  is  all  the  more  likely  to  occur,  as  infected  milk  shows 
no  physical  change. 

Harvey  Littlejohn  has  reported  an  epidemic  occurring  in  Edinburgh 
in  1890,  when  sixty-three  persons,  residing  in  different  parts  of  the  town, 
and  supplied  by  seven  milk-shops,  were  affected  with  typhoid  fever.  On 
investigation,  it  was  found  that  all  these  shops  were  supplied  with  milk 
from  one  farm.  The  farm  itself  was  in  an  exceedingly  insanitary  condition, 
its  water  supply  being  particularly  bad.  Moreover,  one  of  the  children  of 
the  dairyman  was  found  to  be  suffering  from  the  fever.  The  main  interest 
of  this  outbreak  lies  in  the  fact  that  at  first  sight  these  cases  appeared  to 
have  no  connection  with  each  other,  and  were  scattered  irregularly  over  a 
large  area. 

Food. — Cayley  mentions  a  Swiss  epidemic,  where  a  large  number  of 
persons,  who  partook  of  meat  from  a  diseased  calf,  developed  the  fever.  It 
appears  that  in  Switzerland  cattle  are  occasionally  affected  with  what  seems 
to  be  a  form  of  typhoid  fever. 

Eecently  oysters  have  fallen  under  suspicion,  as  being  a  not  infrequent 
source  of  the  disease.  It  appears  that  oyster-beds  are  occasionally  placed 
at  the  mouths  of  rivers  and  near  sewage  effluents,  and  it  is  not  difficult  to 
conceive  that  contamination  may  occur.  Several  epidemics  have  given 
colour  to  this  belief,  and  it  appears  probable  that  restrictions  will  be  placed 
on  the  cultivation  of  oysters  in  certain  localities.  Cockles  eaten  raw  are 
also  suspected  of  having  given  rise  to  typhoid  at  Exeter  in  1899. 

Air. — Foul  air,  especially  in  the  form  of  emanations  from  sewers, 
has  been  long  accused  of  causing  typhoid  epidemics.  Since,  however,  the 
prominent  part  played  by  water  has  been  proved,  there  is  reason  to  believe 


122  GENERAL  DISEASES. 

that  the  risks  of  aerial  infection  have  been  much  exaggerated.  We  must 
admit,  nevertheless,  that  such  infection  occasionally  occurs,  and  Chour  has 
recently  found  the  specific  bacillus  in  the  dust  of  a  barrack -room  in  which 
the  fever  appeared  to  be  endemic.  The  rare  cases  also  of  patients,  admitted 
with  other  diseases,  contracting  the  fever  in  hospitals  where  typhoid  cases 
are  nursed  in  general  wards,  suggest  that  the  dust  of  dried  stools,  carried 
by  the  air,  may  cause  the  infection.  This  view  has  certainly  been 
strengthened  by  a  village  epidemic  in  France,  reported  by  Jeannot  in  the 
spring  of  1898.  The  stools  of  a  typhoid  patient  appear  to  have  been 
carelessly  thrown  on  the  street,  and,  mingling  with  the  dust,  caused  an 
outbreak  of  the  fever.  The  water  supply  was  found  to  be  chemically  and 
biologically  above  suspicion,  and  the  persons  chiefly  affected  were  the 
children  who  were  accustomed  to  play  in  the  street.  As,  moreover,  after 
the  street  was  swept  and  watered  no  further  cases  occurred,  there  seems  little 
doubt  of  the  part  played  by  the  dust  in  the  causation  of  this  epidemic. 

Fomites. — Linen  and  clothes  soiled  by  typhoid  patients  have  trans- 
mitted the  disease  to  nurses,  laundresses,  and  others.  It  is  consequently 
very  necessary  to  disinfect  carefully  all  articles  which  may  possibly  have 
been  exposed  to  the  dejecta  of  the  patient. 

Typhoid  fever  is  not  directly  contagious.  Cases  occurring  among  nurses 
and  attendants  can  be  attributed  to  a  want  of  care  in  cleansing  the  hands, 
or  possibly  to  allowing  stools  passed  in  bed  to  dry  on  the  sheets  and  to  be 
inhaled  as  dust. 

Immunity. — While  it  is  probably  the  fact  that  certain  persons  are  less 
liable  than  others  to  contract  typhoid  fever,  the  only  protection  is  a  previous 
attack  of  the  disease.  Second  attacks  of  the  fever,  though  not  unknown, 
are  certainly  rare.  Eecently  it  has  been  suggested  that  some  persons  are 
born  immune,  this  view  being  based  on  the  fact  that  a  very  large  number 
of  native  children  in  India  give  the  serum  reaction  to  be  alluded  to  later. 
It  is  more  probable,  however,  that  these  children  have  passed  through  mild 
attacks  of  the  disease  in  their  infancy,  the  sanitary  conditions  under  which 
they  live  being  such  as  to  conduce  to  that  being  the  case. 

Wright,  starting  with  the  principle  that  the  serum  reaction  is  a  proof 
of  immunity,  has  recently  introduced  vaccination  for  typhoid  fever.  By 
injecting  dead  cultures  of  the  bacillus,  a  slight  illness  of  a  few  days  is 
caused,  and  the  blood  gives  the  reaction.  But  at  present  it  is  too  early  to 
say  whether  the  persons  so  treated  are  immune. 

Pathology,  and  morbid  anatomy — The  bacillus  of  Eberth 
probably  obtains  entrance  to  the  body,  in  the  vast  majority  of  cases,  by 
the  alimentary  canal.  Even  in  those  instances  where  there  is  reason  to 
suppose  that  the  poison  has  been  inhaled,  it  is  easy  to  see  how  the  germs 
may  find  their  way  down  the  pharynx.  Certain  cases,  however,  which  are 
complicated  from  the  outset  with  pneumonia,  probably  contract  the  disease 
through  the  lungs. 

As  regards  the  subsequent  processes,  there  is  no  little  uncertainty.  It 
has  been  usual  to  regard  the  disease  as  one  primarily  intestinal,  with 
subsequent  general  manifestations.  Sanarelli,  however,  regards  it  as 
primarily  general,  with  subsequent  local  symptoms  chiefly  intestinal,  and 
suggests  that  the  inflammatory  condition  of  the  intestine  is  due  to  the 
elimination  of  the  toxines  given  off  by  the  bacillus.  The  bacillus  itself  has 
certainly  been  discovered  in  all  parts  of  the  body,  though  curiously  enough 
it  is  rarely  found  in  the  blood ;  and,  in  support  of  Sanarelli's  views,  we  may 
cite  the  fact  that  even  cases  presenting  in  life  all  the  classical  symptoms 


TYPHOID  FEVER  123 

of  the  fever,  have  been  found  after  death  to  have  a  perfectly  normal 
intestine,  even  though  pure  cultures  of  the  bacillus  may  be  obtained  from 
the  spleen  and  elsewhere.  Moreover,  many  of  the  severest  cases  show 
extraordinarily  little  intestinal  disease  when  examined  post-mortem. 

Without  entering  further  into  this  question,  we  may  accept  it  as  a  fact 
that  the  bacillus  of  Eberth  has  a  preference  for  certain  organs,  and  it 
appears  to  select  specially  the  Peyer's  patches  in  the  lower  part  of  the 
ileum,  the  solitary  glands  in  the  same  locality,  the  mesenteric  glands,  and 
the  spleen.  It  has  also  been  frequently  found  in  the  liver,  kidneys,  and 
lungs.  In  these  various  positions  it  appears,  after  a  certain  period,  to  set 
free  toxines,  to  the  action  of  which  we  may  presume  the  general  symptoms 
of  the  disease  are  due. 

Changes  in  Peyer's  patches. — The  affection  of  Peyer's  patches,  after 
the  bacilli  have  obtained  a  nidus  within  them,  appears  to  be  primarily 
an  infiltration  with  leucocytes.  The  patch  becomes  pinkish  in  colour, 
and  is  gradually  raised  above  the  level  of  the  surrounding  mucous 
membrane  of  the  intestine.  The  patches  show  a  varying  degree  of  hard- 
ness, some  being  very  soft  and  of  a  dark  red  colour  when  they  are  fully 
developed,  while  others  are  paler,  firmer,  and  more  raised  above  the 
surface.  French  authors  have  distinguished  these  by  the  names  of  plaques 
molles  and  plaques  dures  respectively,  but  the  distinction  is  of  little 
importance,  as  the  process  is  apparently  the  same  in  both  cases. 

After  the  process  of  infiltration  has  continued  for  a  period,  which  varies 
in  duration  in  different  cases,  the  second  stage,  that  of  necrosis,  commences. 
The  enlarged  mass  gradually  sloughs  away,  either  as  a  whole  or  more 
frequently  in  detached  fragments.  It  is  probable  that  this  change  begins 
about  the  tenth  or  twelfth  day  of  the  fever,  and  that  occasionally  in  abortive 
cases  it  is  dispensed  with  altogether,  the  gland  resuming  the  normal  by  a 
process  of  absorption.  If  necrosis  does  occur,  the  sloughing  mass  becomes 
greyish  in  colour,  and  is  frequently  stained  a  bright  yellow  on  the  surface. 

The  separation  of  the  slough  is  usually  complete  by  about  the  end  of 
the  third  week,  by  which  time  the  typical  typhoid  ulcer  is  formed.  The 
ulcer  may  show  a  varying  degree  of  depth,  the  muscular  coat  being 
frequently  involved,  while  occasionally  the  base  is  formed  by  the  peritoneal 
coat  completely  denuded.  In  shape  it  usually  corresponds  to  the  outline 
of  the  Peyer's  patch  itself,  but  occasionally,  owing  to  the  gland  having 
sloughed  only  in  part,  it  may  assume  very  irregular  forms.  Its  coalescence, 
moreover,  with  other  ulcers  or  with  diseased  solitary  glands  may  present 
an  ulcerated  surface  of  considerable  extent  and  irregular  outline.  It  may 
be  distinguished  from  tuberculous  disease  by  its  long  axis  being  parallel  to 
that  of  the  bowel,  and  its  primary  situation  being  opposite  the  peritoneal 
attachment  of  the  gut.  Its  edges,  moreover,  do  not  show  that  induration 
which  is  so  characteristic  of  both  base  and  edges  of  the  tuberculous  ulcer. 

The  typhoid  ulcer  has  three  possibilities  before  it.  It  may  become 
chronic  and  exist  for  several  weeks  before  taking  on  a  healing  process,  it 
may  perforate,  or,  lastly,  it  may,  and  usually  does,  undergo  a  process  of  repair. 

Perforation  of  the  ulcer  may  occur  in  three  ways.  First,  there  may  be 
a  gradual  extension  in  depth  of  the  necrotic  process,  which  ultimately 
reaches  the  peritoneal  coat  and  works  through  it.  In  such  a  case,  which  is 
most  usual,  the  perforation  is  usually  small;  hardly  larger,  indeed,  than 
an  ordinary  pin's  head.  Second,  the  whole  Peyer's  patch,  including  the 
entire  thickness  of  the  tissues  beneath  it,  may  slough  completely  away, 
and  as  it  were  drop  out,  leaving  an  opening  corresponding  to  the  size  of 


i24  GENERAL  DISEASES. 

the  gland  itself.  Third,  in  certain  cases  where  the  slough  has  separated,  and 
where  the  floor  of  the  ulcer  is  formed  merely  by  the  peritoneal  coat,  the 
latter  may  give  way  and  present  the  appearance  of  having  been  torn  across. 

In  looking  for  a  perforation  post-mortem,  great  care  has  to  be  exercised 
in  the  handling  of  the  bowel.  In  such  cases  there  is  always  more  or  less 
peritonitis,  and  flakes  of  purulent  lymph  occasionally  hide  the  lesion. 
Before  removing  the  bowel,  it  is  advisable  to  examine  the  most  acutely 
inflamed  parts  in  situ,  gently  wiping  off  any  adherent  lymph  with  a  sponge. 
Attention  will  first  be  paid  to  the  last  foot  of  the  ileum  above  the  ileo- 
csecal  valve,  the  vast  majority  of  perforations  occurring  in  that  locality.  If, 
after  removal,  the  bowel  is  flushed  through  under  a  tap,  artificial  perfora- 
tions may  readily  occur.  It  is  safer  to  open  the  gut  before  washing  it, 
allowing  merely  a  gentle  stream  of  water  to  trickle  over  it  and  wash  away 
the  faecal  matter. 

Repair. — If,  after  the  separation  of  the  slough,  the  ulcer  escapes  perfora- 
tion, it  gradually  heals.  Small  granulations  appear  on  its  surface,  and 
these  are  gradually  covered  by  the  mucous  membrane  growing  in  from  the 
edges.  Very  little  true  cicatricial  tissue  is  formed,  and,  as  a  result,  there 
is  no  contraction  of  the  gut.  A  few  weeks  after  the  disease  has  terminated, 
all  that  can  be  seen  is  the  so-called  "  shaven-beard  "  appearance,  minute 
black  dots  on  a  greyish  surface.  The  glandular  tissue,  however,  is  not 
restored. 

Other  intestinal  changes. — A  process  similar  to  that  detailed  above 
occurs  in  the  solitary  glands.  Occasionally,  indeed,  these  glands  are  alone 
affected,  Peyer's  patches  completely  escaping,  thus  giving  rise  to  what 
has  been  termed  the  "  pustular  "  form  of  the  disease.  In  many  instances 
the  glands  of  the  large  intestine  also  ulcerate,  particularly  those  in  the 
neighbourhood  of  the  ileo-cascal  valve.  The  vermiform  appendix  is  some- 
times ulcerated,  and  perforation  may  occur  in  this  locality. 

The  mucous  membrane  of  the  intestine  is  frequently  brightly  injected, 
and  the  position  of  the  ulcers  may  be  marked  on  the  external  surface  of 
the  bowel  by  patches  of  deep  congestion.  The  bowel  wall  itself  in  severe 
cases  shows  very  marked  thinning  and  atrophy. 

The  mesenteric  glands  are  always  enlarged,  often  to  a  considerable 
extent.  They  are  pinkish  in  section,  and  occasionally  are  softened  and 
diffluent  in  the  centre.  Cultures  of  Eberth's  bacillus  may  be  obtained 
from  them,  but  the  B.  coli  communis  is  often  also  present. 

Changes  in  other  organs. — The  spleen  is  dark  in  colour,  and  almost 
invariably  is  much  enlarged,  being  often  three  or  four  times  its  natural  size. 
Occasionally  it  is  diffluent.  On  microscopic  examination,  small  masses  of 
bacilli  may  be  seen  lying  in  the  cells.  If  cultures  are  desired,  the  post- 
mortem examination  should  be  made  well  within  twenty-four  hours  after 
death,  or  a  hypodermic  needle  used  to  suck  up  a  little  of  the  pulp  from 
the  organ. 

The  heart  shows  degeneration  of  the  cardiac  muscle,  with  occasionally 
marked  thinning  of  the  walls.     It  is  usually  pale  and  flabby. 

The  other  organs  show  no  special  or  characteristic  change,  though 
ulcerations  are  sometimes  found  in  the  larynx  and  pharynx,  and  the  lungs 
of  severe  cases  show  more  or  less  hypostatic  congestion. 

Symptomatology. — The  period  of  incubation  in  typhoid  fever  is  by 
no  means  settled.  It  has  been  stated  at  as  long  a  period  as  three  weeks 
and  as  short  as  one  week.  During  this  time  the  patient  may  or  may  not 
feel  ill. 


TYPHOID  FEVER. 


i25 


The  invasion  is  less  marked  in  a  large  proportion  of  cases  than  that  of 
any  other  fever,  and  it  is  a  practical  difficulty  to  ascertain  accurately  the 
exact  day  of  the  commencement  of  the  disease,  even  when  the  case  is 
brought  under  observation  early.  Moreover,  the  patient  may  occasionally 
go  about  during  a  considerable  time  after  the  symptoms  have  set  in. 

The  general  clinical  history  of  an  average  case  of  typhoid  fever  may  be 
conveniently  described,  according  to  the  weeks  of  its  progress  as  follows : — 


Events  of  the  First  Week. 

The  onset  is  marked  by  feelings  of  chilliness  with  discomfort  and 
languor,  and  a  sense  of  feverishness,  more  especially  at  night.  Headache  is 
an  early  symptom.  It  may  assume  the  form  of  severe  neuralgic  pain,  and 
may  be  located  in  one  side  of  the  head,  or,  on  the  other  hand,  there  may  be 
only  the  dull  frontal  headache,  so  often  accompanying  feverish  attacks. 
Giddiness  is  often  complained  of,  particularly  on  sitting  up.  Epistaxis, 
slight  or  severe,  is  not  uncommon  at  a  very  early  stage,  and  indeed  the 
occurrence  of  this  symptom,  especially  when  accompanied  by  febrile  pheno- 


Day  of 
Disease 

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6 

7 

8 

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27 

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Fig.  6. — A  moderately  severe  case  of  typhoid  fever  in  a  female,  set.  22. 

mena,  may  well  arouse  a  suspicion  of  typhoid.  There  is  thirst,  loss  of  appetite, 
and  occasionally  gastric  irritation  with  sickness.  The  tongue  is  moist,  with 
a  somewhat  creamy  fur  on  the  dorsum,  and  redness  of  the  tip  and  edges. 

The  temperature  is  one  of  the  most  noteworthy  and  characteristic 
symptoms  of  this  period.  It  shows  an  evening  rise  of  1°  or  2°,  a  fall 
of  1°  or  less  next  morning,  succeeded  by  a  further  rise  each  evening 
to  a  higher  point  than  the  preceding,  along  with  a  slight  morning  re- 
mission, so  that  the  febrile  movement  has  a  somewhat  climbing  or  step- 
like arrangement. 

By  the  end  of  the  first  week,  the  evening  temperature  may  have 
attained  to  the  height  of  102°,  103°,  or  more.  The  pulse,  although 
quickened,  is  not  increased  in  proportion  to  the  temperature.  It  is  full 
and  soft.  The  skin  is  dry.  Constipation  is,  as  a  rule,  present.  The 
abdomen  is  somewhat  fuller  than  normal,  and  there  may  be  tenderness  on 
pressure  over  the  right  iliac  fossa,  where  also  slight  gurgling  may  be  made 
out.  The  splenic  dulness  is  increased.  By  the  end  of  the  first  week  the 
patient  has  acquired  a  somewhat  prostrate  appearance,  and  the  face  shows 
a  slight  flush  over  the  malar  regions,  especially  in  the  evening.  The  eye 
looks  lustrous  and  the  pupils  are  dilated. 


i26  GENERAL  DISEASES. 


Events  of  the  Second  Week. 


Most  of  the  phenomena  characterising  the  first  week  are  intensified, 
and  the  patient  appears  to  be  more  in  the  grasp  of  the  disease.  The 
temperature  has  risen  to  103°-104°,  and,  while  it  shows  slight  remission 
in  the  morning,  is  more  continuously  high  than  during  the  first  week. 
The  pulse,  too,  is  somewhat  more  rapid,  although  in  mild  cases  it  may 
still  be  comparatively  slow.  It  is  of  low  tension,  and  often  shows 
marked  dicrotism.  Two  important  diagnostic  phenomena  make  their 
appearance  during  this  week,  namely,  eruption  on  the  skin  and  diarrhoea. 
About  the  seventh  or  eighth  day,  on  examining  the  front  of  the  trunk  of 
the  body,  the  characteristic  eruption  will  in  most  cases  be  observed. 
It  consists  of  isolated  spots  from  one  to  three  lines  in  diameter,  of 
rose-pink  colour,  slightly  elevated  above  the  level  of  the  skin.  They  are 
most  readily  seen  on  the  abdomen.  There  may  be  only  a  few  to  be  noticed 
at  first,  but  they  increase  in  number,  coming  out  in  crops  from  day  to  day — 
the  earlier  spots  tending  to  become  darker  red  prior  to  their  fading  away. 
The  eruption  is  absent  in  a  considerable  number  of  cases,  especially  in 
children.  Other  appearances  of  the  skin  are  occasionally  observed,  especi- 
ally pale  bluish  patches  (touches  bleudtres).  The  eruption  continues  during 
the  greater  part  of  the  febrile  stage  of  the  disease,  and  also  in  any  recrud- 
escences or  relapses  which  may  occur. 

It  is  during  the  second  week  also  that  diarrhoea  makes  its  appearance. 
Unattended  as  a  rule  by  pain,  the  action  of  the  bowels  may  be  severely  or 
only  slightly  disturbed.  The  stools  are  of  ochre-yellow  colour,  and  have  a 
resemblance  to  pea-soup.  They  are  of  alkaline  reaction,  and  have  a  heavy 
foetid  odour.  They  may  contain  particles  of  undigested  food,  together  with 
epithelium  and  fragments  of  slough  from  the  intestinal  ulcers,  and  in  them 
may  be  detected  the  bacilli  of  typhoid.  Blood  may  be  mixed  with  the 
stools :  occasionally  there  is  copious  haemorrhage.  The  abdomen  is  now 
more  distended,  and  tenderness  continues  to  be  present  in  the  right  iliac 
fossa.  The  tongue  is  still  coated,  but  is  now  dry  and  fissured.  Delirium 
of  mild  character  may  be  present,  especially  at  night.  During  the  day  the 
mental  condition  is  tolerably  clear,  but  the  patient  is  dull  and  listless,  due 
probably  in  some  measure  to  deafness,  which  is  common  at  this  stage. 

Events  of  the  Thikd  Week. 

The  symptoms  of  the  second  week  continue  during  the  third,  and 
usually  in  an  aggravated  form.  The  temperature  remains  almost  con- 
stantly high,  with  slight  morning  remissions.  The  pulse  is  hurried,  110 
to  120,  and  feebler.  Diarrhoea  may  become  "more  urgent.  The  most 
obvious  appearance  is  that  of  greatly  increased  prostration.  The  patient 
lies  low  in  bed,  and  has  a  look  of  apathy  and  weakness.  He  is  much 
thinner,  and  his  muscles  are  tremulous  on  effort.  There  is  considerable 
somnolence,  with  low  muttering  delirium.  Not  infrequently  there  is 
cough  with  quickened  respiration,  the  result  of  pulmonary  congestion.  It 
is  during  this  week  that  the  more  serious  complications  of  the  fever, 
namely,  haemorrhage  and  perforation,  are  most  apt  to  occur. 

Events  of  the  Fourth  Week. 

As  a  rule  the  fever  begins  to  show  signs  of  yielding — the  temperature 
tending  to  fall  to  a  lower  point  in  the  morning,  while  it  does  not  attain  to 


TYPHOID  FEVER. 


127 


such  a  high  degree  in  the  evening,  thus  tending  to  assume  an  intermittent 
character.  A  favourable  change  takes  place  in  all  the  other  symptoms, 
and  although  reduced  to  a  condition  of  great  weakness,  the  patient  begins 
to  advance  to  convalescence.  Even  during  this  period,  however,  there 
may  arise  recrudescence  of  the  febrile  symptoms  for  short  periods,  and 
occasionally  a  distinct  relapse. 

Some  cases  pass  through  the  fourth  week  without  any  change,  and  there 
may  be  no  signs  of  cessation  of  the  fever  until  the  fifth  or  sixth  week.  In 
such  instances  the  patient  becomes  extremely  emaciated  and  exhausted. 

Analysis  of  the  chief  symptoms  of  the  fever,  including  its  more 
important  complications. — Invasion. — There  are  few  diseases  where  the 
mode  of  onset  is  so  varied.  On  the  one  hand,  there  are  cases  so  benign 
that  the  actual  beginning  of  the  fever  escapes  notice,  while,  on  the 
other,  the  symptoms  may  be  extremely  severe ;  or,  again,  they  may 
be  mixed  up  with  other  morbid  phenomena  not  belonging  to  the  fever, 
in  such  a  way  as  to  render  an  early  diagnosis  a  matter  of  difficulty. 


Day  of 

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Fir.  7. — A  severe  case  of  typhoid  fever,  showing  a  tendency  to  hyperpyrexia  on  the 
twenty-sixth  day.     A  male,  set,  23. 

Thus  pulmonary  symptoms,  in  the  form  of  catarrh  or  even  pneumonia,  may 
be  the  most  prominent  features  present  at  the  commencement  of  the 
fever ;  or,  again,  severe  gastro-intestinal  irritation.  In  the  case  of  children, 
nervous  symptoms,  suggestive  of  meningitis,  are  not  at  all  uncommon,  and 
may  readily  mask  the  real  nature  of  the  disease  at  its  onset.  The  so-called 
"  ambulatory  form  "  of  typhoid  includes  those  cases  where  the  patient  goes 
about  for  some  time  with  the  symptoms  of  the  fever  upon  him,  before 
placing  himself  under  medical  treatment,  as  well  as  those  where  the 
disease  remains  wholly  undiscovered  and  untreated,  until  some  serious 
complication  arises,  such  as  haemorrhage  or  perforation. 

Temperature. — The  course  of  the  temperature  is  one  of  the  most  signi- 
ficant features  of  typhoid  fever.  In  its  typical  form  it  presents  a  move- 
ment which  may  be  divided  into  three  stages,  comprehending  a  period  of 
ascent,  a  period  of  continuance,  and  a  period  of  decline,  which  in  a  general 
way  might  be  graphically  represented  by  the  figure  of  a  semicircle.  Daily 
remissions  in  the  morning,  to  a  greater  or  less  degree,  characterise  the 
temperature  throughout. 


128  GENERAL  DISEASES. 

During  the  first  week  there  is  a  daily  progressive  ascent  of  the  evening 
temperature,  with  slight  morning  remission,  and  by  the  end  of  the  week  in 
an  average  case  the  maximum  is  attained.  During  the  second  week  the 
temperature  is  more  continuously  high,  only  such  a  slight  remission  occur- 
ring in  the  morning  as  is  analogous  to  that  of  health  ;  and  this  is  the  case 
throughout  the  greater  part  of  the  third  week,  by  the  end  of  which  time, 
however,  a  change  in  the  temperature  curve  may  be  observed,  the  morning 
remissions  especially  being  more  decided  and  the  evening  rises  not  so  great. 

In  the  fourth  week  the  temperature  approximates  to  the  intermittent 
type,  that  of  the  morning  being  frequently  normal,  with  sharp  rises  of  short 
duration  in  the  evening,  which,  however,  soon  subside,  and  there  is  a  steady 
return  by  lysis  to  the  normal.  It  is  generally  held  that  the  attack  has 
come  to  an  end  when  the  temperature,  both  morning  and  evening,  is  at  the 
normal  point  for  at  least  a  week,  but  recrudescences  or  relapses  of  the 
fever  are  not  uncommon. 

In  observing  the  course  of  the  temperature  from  day  to  day,  during  the 
progress  of  the  fever,  it  will  generally  be  found  that  the  highest  point  is 
attained  from  eight  to  twelve  o'clock  in  the  evening,  and  the  lowest  from 
six  to  eight  in  the  morning.  As  a  general  rule,  there  is  only  one  maximum 
in  the  day,  but  observations  taken  at  frequent  intervals  may  show  somewhat 
greater  fluctuations  in  the  temperature  than  can  be  made  out  when  only 
morning  and  evening  records  are  made. 

Many  conditions  may  modify  the  course  of  the  temperature  in  typhoid. 
Those  cases  in  which  diarrhoea  is  a  prominent  symptom  usually  show  high 
temperatures,  often  without  much  remission.  The  occurrence  of  intestinal 
haemorrhage  produces  a  sudden  and  marked  fall  in  the  temperature,  and  it 
has  been  noticed  that  in  such  cases  the  subsequent  thermometric  readings 
lose  their  typical  character  and  become  irregular. 

Hyperpyretic  rises  (106°  and  upwards)  are  not  common,  and  are  gener- 
ally of  evil  omen.  The  temperature  is  readily  influenced  by  treatment 
with  antipyretics,  such  as  the  cold  bath,  which  will  be  referred  to  subse- 
quently. During  convalescence  the  temperature  may  show  slight  fluctua- 
tions from  the  normal,  as  the  result  of  changes  in  the  diet,  or  moving  out 
of  bed,  and  observations  should  be  frequently  taken  in  this  stage.  It  is 
probable  that  the  temperature  in  typhoid  fever  stands  in  some  relation  to 
the  bowel  lesion,  those  cases  where  extensive  and  long-lasting  ulceration 
exist  exhibiting  a  high  and  long-continuing  febrile  range,  while  relapses  or 
recrudescences  probably  are  associated  with  fresh  formation  or  the  non- 
healing of  ulcers.  Doubtless,  however,  short  outbursts  of  high  temperature  in 
the  convalescence  may  be  due  to  less  serious  causes,  as  seen  in  other  acute 
diseases.  Inverse  temperatures  (highest  in  the  morning  and  lowest  in  the 
evening)  are  sometimes  met  with,  and  have  been  occasionally  observed  among 
night  nurses  in  hospitals  when  suffering  from  the  disease.  Cases  of  typhoid 
fever  without  febrile  temperature  have  occasionally  been  met  with. 

Circulation. — The  pulse  exhibits  many  features  of  interest.  In  a  large 
number  of  cases  of  moderate  severity,  it  is  in  the  early  stage  comparatively 
infrequent,  showing  a  want  of  relation  to  the  height  of  the  temperature  ;  and 
in  some  instances  this  absence  of  correspondence  continues  throughout. 
Generally,  however,  the  pulse  tends  to  increase  in  frequency  as  the  disease 
advances,  and  all  the  more  if  diarrhoea  is  present.  It  is  at  first  full  and 
soft,  but  soon  becomes  smaller  and  dicrotic.  In  the  later  stages  of  the 
fever,  it  may  become  unsteady  and  irregular.  A  pulse  of  over  120  in  an 
adult  is  to  be  viewed  with  anxiety. 


TYPHOID  FEVER.  129 

"When  haemorrhage  occurs  the  pulse  rate  increases,  while  the  temperature 
falls ;  and,  should  perforation  take  place,  symptoms  indicating  collapse 
make  themselves  manifest  in  the  circulation.  In  convalescence,  the  pulse, 
like  the  temperature,  should  be  carefully  observed.  Sometimes  it  continues 
frequent  from  sheer  weakness,  or  from  nervous  perturbation.  Less  fre- 
quently it  is  abnormally  rare.  The  heart  gives  evidence  of  feebleness  as 
the  fever  advances  in  the  weakened  impulse  and  diminished  strength  of 
the  first  sound,  as  well  as  in  the  accompanying  pulmonary  congestion. 

Thrombosis  affecting  the  femoral  vein — usually  the  left — is  an  occa- 
sional accompaniment  or  sequel  of  typhoid  fever.  It  gives  rise  to 
enlargement  and  oedema  of  the  limb,  "  swelled  leg."  It  occurs  in  the 
later  part  of  the  fever,  or  in  the  early  stages  of  convalescence.  Although  a 
troublesome  symptom,  it  is  rarely  attended  with  serious  results  ;  neverthe- 
less it  is  not  entirely  without  the  risk  of  the  dangers  accompanying  an 
extension  of  the  thrombus  or  its  detachment.  Arterial  obstruction  of  a 
limb,  with  resulting  gangrene,  has  been  described  in  this  as  in  other  acute 
febrile  diseases,  but  it  is  very  rare. 

The  condition  of  the  blood  in  typhoid  fever  has  been  investigated, 
especially  by  Osier  and  Thayer.  It  would  appear  that,  while  in  the 
early  stages  of  the  fever  little  or  no  change  is  observed  in  the  blood, 
as  the  disease  advances  a  marked  diminution  in  the  red  corpuscles  and 
especially  in  the  haemoglobin  takes  place.  There  is  no  leucocytosis,  but 
certain  variations  from  the  normal  in  the  relative  proportions  of  the 
different  forms  of  the  leucocytes  have  been  detected,  the  polynuclear 
neutrophiles  being  diminished  and  the  large  mononuclear  and  transitional 
varieties  increased. 

Respiratory  System. — As  is  the  case  in  most  febrile  disorders,  the  re- 
spiration is  quickened,  and  this  may  become  very  marked  as  the  disease 
advances.  Certain  respiratory  affections  are  apt  to  occur.  Bronchial 
catarrh  is  a  very  common  symptom,  and  is  manifested  by  cough  and 
the  presence  of  diffuse  moist  and  dry  sounds.  Hypostatic  congestion  and 
oedema  of  the  lungs  are  apt  to  be  present  in  the  later  stages  of  the  fever, 
and  may  form  a  serious  complication.  Lobar  pneumonia  may  be  met  with 
at  any  stage,  and  should  it  occur  early  may  mask  the  symptoms  of  the 
fever.  Other  respiratory  disorders  have  been  described  as  complicating 
typhoid,  such  as  laryngitis,  pleurisy,  etc.,  but  they  are  of  comparatively  rare 
occurrence. 

Digestive  System. — The  tongue  is  at  first  large,  moist,  and  coated 
with  a  whitish  yellow  fur,  except  at  the  edges  and  tip,  where  it  is  red. 
Occasionally,  for  some  time  after  the  commencement,  the  tongue  shows 
more  markedly  a  febrile  character,  becoming  dry  and  brown  in  the  centre, 
with  a  white  stripe  on  either  side,  the  edges  and  tip  continuing  red.  Later 
on  the  tongue  acquires  a  uniform  dry,  red,  glazed,  and  often  fissured 
appearance,  with  some  incrustation  of  sordes  upon  it.  The  fauces  show 
considerable  irritation  in  the  early  stage  of  the  fever,  which  may  lead  to  an 
error  in  diagnosis.  In  the  later  stage  the  irritable  condition  of  the  throat 
may  become  a  serious  hindrance  to  swallowing.  Thirst  and  loss  of  appetite 
are  the  rule,  but  in  mild  cases  neither  of  these  may  be  prominent  symptoms. 
Vomiting  is  not  common  in  the  early  stage,  but  when  it  does  occur  to  any 
great  extent  is  usually  indicative  of  a  severe  case. 

Diarrhoea  is  one  of  the  most  characteristic  symptoms  of  typhoid  fever,  but 
it  is  by  no  means  always  present.  It  occasionally  occurs  from  the  outset,  but 
more  commonly  appears  in  the  course  of  the  second  week,  and  continues 
vol.  1. — g 


130 


GENERAL  DISEASES. 


till  the  end  of  the  fever,  returning  again  in  any  relapse.  The  amount 
varies  greatly.  In  average  cases  there  may  be  four  or  five  loose  motions  in 
a  day,  but  in  the  severer  forms  there  may  be  as  many  as  from  ten  to  twenty. 
The  appearance  of  the  stools  has  already  been  described.  Although  the 
amount  of  the  diarrhoea  does  not  appear  to  bear  any  necessary  relation  to 
the  extent  of  the  intestinal  lesion,  yet  this  symptom  even  by  itself  may  be 
a  source  of  danger,  and  indeed  is  not  infrequently  the  cause  of  a  fatal 
termination.  In  some  cases  constipation  is  present  throughout  and 
requires  special  and  careful  treatment,  as  by  the  incautious  employment 
of  purgatives  diarrhoea  may  be  set  up.  Constipation  is  not  a  favourable 
symptom,  and  should  be  treated. 

Meteorism  or  abdominal  distension,  either  accompanying  diarrhoea  or 
apart  from  it,  is  sometimes  a  symptom  which  causes  much  discomfort.     Its 

persistence  usually  marks  a 
severe  case,  and  it  increases 
the  risk  of  perforation. 

Hemorrhage  may  occur  at 
any  period  in  the  course  of  the 
fever,  but  it  is  most  common 
about  the  end  of  the  second 
and  during  the  third  weeks. 
Its  amount  varies,  but  its 
presence  is  always  to  be  re- 
garded with  anxiety,  since, 
although  not  necessarily  an 
unfavourable  symptom,  it  may 
readily  become  so  by  its 
amount,  or  by  the  condition 
in  which  the  patient  is  at  the 
time  of  its  occurrence.  The 
mortality  in  those  cases  of 
typhoid  which  have  been  com- 
plicated by  haemorrhage  ap- 
pears to  be  at  least  twice 
greater  than  the  average.  The 
occurrence  of  this  symptom 
may  be  suspected  by  a  sudden 
fall  in  the  temperature,  a  rapid 
feeble  pulse,  on  percussion  dulness  in  the  left  iliac  region,  and  marked 
pallor  of  the  face.  Occasionally  other  haemorrhages,  such  as  epistaxis, 
occur  at  the  same  time  as  that  from  the  intestines,  and  add  to  the  gravity 
of  the  prognosis. 

Perforation  is  the  most  dreaded  of  all  the  symptoms  of  typhoid  fever,  but 
it  is  happily  a  rare  occurrence,  the  proportion  of  cases  being  from  2  to  3  per 
cent.  It  is  more  apt  to  happen  where  the  intestinal  symptoms — diarrhoea, 
haemorrhage,  and  meteorism — have  been  conspicuous ;  but  it  occasionally 
occurs  where  there  has  been  constipation  throughout,  and  in  some  instances 
in  the  milder  or  ambulatory  forms.  It  seems  more  common  in  males  than  in 
females.  The  period  of  its  occurrence  is  as  a  rule  late,  usually  in  the  third 
or  fourth  week,  also  during  convalescence,  or  in  a  relapse.  It  may  take  place 
without  any  apparent  immediate  cause ;  on  the  other  hand,  it  has  been  seen 
to  follow  some  error  in  diet,  or  exertion  such  as  vomiting,  straining  at  stool, 
and  moving  out  of  bed.     It  is  characterised  by  sudden  intense  pain  in  the 


Day  of 
Disease 

G. 
-40° 

F. 
104° 

«9 

S 

39° 
38° 
-37 



102° 

101° 

100° 

99° 

98 
97° 

1     r< 
\    e 

M 
Pulse 

E 

I22  / 
/MS 

114  / 
/1O8 

108/ 
/  128 

120/ 
/  I20 

100/ 
/120 

lOo/ 
/I20 

152/ 

/\ 144 

152/ 

Motions 

O 

3 

3 

3 

1 

3 

1 

0 

Fig.  8. — Case  of  a  female,  set.  17,  terminating 
fatally  by  hasmorrhage. 


TYPHOID  FEVER. 


!3r 


lower  part  of  the  abdomen,  which  soon  becomes  diffused  and  general,  and 
is  followed  by  vomiting  and  symptoms  of  collapse ;  these  latter  are  often  the 
most  reliable,  as  they  are  sometimes  the  only,  evidences  of  perforation 
having  taken  place.  Symptoms  of  peritonitis  supervene,  and  the  patient 
seldom  survives  more  than  one  or  two  days.  In  some  rare  instances 
spontaneous  recovery  seems  to  take  place,  and  in  others  surgical  interven- 
tion has  succeeded  in  reaching* and  closing  up  the  perforation,  although  in 
general  the  patient's  condition  is  very  unfavourable  for  an  operation. 
Peritonitis  appears  occasionally  to  occur  without  perforation. 

Urinary  System.  —  The  urine  at  the  first  presents  the  characters 
common  to  all  febrile  disorders,  being  concentrated  and  dark  in  colour. 
The  urea  is  increased  in  amount,  especially  in  the  early  stage,  and  more  or 
less  throughout  the  course  of  the  fever,  the  increase  being  more  marked 
when  the  temperature  is  high.  The  uric  acid  is  also  increased  in  amount, 
but  the  chlorides  are  diminished,  and  albumin  may  be  present  to  a  slight 
extent.  In  the  convalescence  the  urine  regains  its  normal  character. 
Acute  nephritis  may  arise  as  a  complication  of  the  fever. 

Eetention  of  urine  is  apt  to  occur 
in  severe  cases,  and  the  condition  of 
the  bladder  should  always  be  carefully 
watched. 

A  character  of  the  urine  in  typhoid 
fever  is  described  by  Ehrlich,  namely, 
its  so-called  diazo-reaction.  This  is 
produced  as  follows:  Two  solutions 
are  employed — a  saturated  solution 
of  sulpbanilic  acid  in  a  5  per  cent, 
solution  of  hydrochloric  acid;  a  \  per 
cent,  solution  of  sodium  nitrite. 

A  few  c.c.  of  the  urine  are  placed 
in  a  test-tube,  together  with  an  equal 
quantity  of  solution  1.  To  this  are 
added  a  few  drops  of  solution  2.  The 
mixture  is  then  rendered  alkaline  by 
the  addition  of  ammonia  which  is 
allowed  to  run  carefully  down  the  side 
of  the  test-tube.  At  the  junction 
of  the  ammonia  with  the  urine  a  brownish  red  ring  is  formed,  if  the 
reaction  takes  place,  and  if  then  shaken  up  both  the  fluid  and  the  froth  are 
of  port-wine  colour.  This  is  not  present  in  normal  urine.  Unfortunately, 
the  value  of  the  reaction  as  a  diagnostic  is  lessened  by  the  fact  that  it  may 
be  met  with  in  the  urine  in  tuberculosis  and  other  febrile  conditions. 
Nevertheless,  it  is  of  use  as  a  confirmatory  test,  since  it  is  present  in  the 
great  majority  of  cases  of  typhoid  fever. 

Integumentary  System. — Besides  the  characteristic  eruption  of  typhoid 
fever,  already  described,  other  abnormal  appearances  of  the  skin  may 
occasionally  be  observed.  Erythematous  eruptions,  more  or  less  severe, 
and  extensive  patches  of  urticaria,  and  the  still  more  common  sudaminal 
rashes,  all  may  be  met  with,  and  may  interfere  to  some  extent  with 
accurate  diagnosis.  Boils  and  skin  abscesses  during  convalescence  are  not 
very  infrequent. 

Nervous  System. — The  headache  usually  present  at  the  outset  has 
already  been  alluded  to. 


Fig.  9. — Fatal  termination  by  perforation 
in  a  female,  set.  22. 


1 32  GENERAL  DISEASES. 

In  the  milder  forms,  delirium  may  be  entirely  absent  throughout. 
In  ordinary  cases,  however,  it  is  not  unusual  after  the  first  week,  and 
especially  at  night.  The  type  is  quiet  and  muttering;  rarely,  though 
occasionally,  noisy  and  violent,  "  delirium  ferox."  Associated  with  this 
symptom  there  is  frequently  some  amount  of  mental  confusion,  which  is 
apt  to  be  aggravated  by  the  deafness  so  often  present.  In  severe  forms 
of  the  fever,  and  in  the  later  stages,  the  conditions  characteristic  of  the 
"  typhoid  state  "  are  observed,  namely,  great  prostration  and  apathy,  with 
muttering  delirium,  and  sometimes  coma  or  coma  vigil.  Muscular  rigidity, 
affecting  especially  the  legs,  is  sometimes  present  in  the  early  stage.  It 
may  involve  other  muscles,  such  as  those  of  the  neck,  and  give  rise  to 
retraction  of  the  head,  very  like  that  met  with  in  tuberculous  meningitis. 
Muscular  tremors  are  frequently  present  in  the  later  stages  of  the  fever, 
and  are  usually  associated  with  great  muscular  weakness.  Subsultus 
tendinum  is  a  common  late  symptom. 

Convulsions  are  of  very  rare  occurrence.  Cutaneous  hyperesthesia  is 
occasionally  met  with,  especially  in  women  and  children.  It  affects  mostly 
the  lower  parts  of  the  abdomen  and  the  limbs.  It  is  apt  to  simulate  peri- 
tonitis. Cutaneous  anaesthesia  is  very  rare,  and  hearing  is  often  impaired. 
It  first  shows  itself  by  noises  in  the  head,  which  are  succeeded  by  deafness, 
often  to  an  extreme  degree.  Sometimes  only  one  ear  is  affected.  Otitis 
media  is  of  rare  occurrence.  The  existence  of  deafness  is  in  some  instances 
of  considerable  diagnostic  value.  This  symptom  passes  away  after  defer- 
vescence, and  it  is  seldom  that  the  hearing  is  permanently  affected. 

Although  vision  is  not  much  affected  in  typhoid  fever,  the  eyes  show 
some  points  of  clinical  importance.  The  pupils  are  in  general  dilated,  and 
the  eyes  have  a  somewhat  lustrous  appearance,  while  the  conjunctivas  are, 
as  a  rule,  free  from  injection,  such  as  is  seen  in  typhus. 

Relapse  in  typhoid  fever. — The  term  is  applied  to  a  return  of  the 
fever  during  the  stage  of  convalescence.  A  distinction  must,  however,  be 
made  between  the  mere  occurrence  of  short  febrile  recrudescences  at  this 
period,  which,  as  already  mentioned,  may  be  associated  with  changes  in 
diet  and  other  obvious  causes,  and  a  true  relapse,  in  which  all  the  pheno- 
mena of  the  primary  attack  are  repeated,  although  usually  in  miniature. 
The  relapse,  which  seems  more  often  to  occur  in  the  severer  forms  of  the 
fever,  is  announced  by  a  gradual  ascent  of  the  temperature  as  at  first,  and 
by  the  appearance  of  the  other  symptoms,  such  as  the  increased  pulse 
rate,  dry  tongue,  and  diarrhoea.  The  rash  also  frequently  returns,  but  it 
has  been  noticed  that  it  is  earlier  in  appearing  than  during  the  primary 
attack.  The  relapse  is,  as  a  rule,  of  shorter  duration  than  the  original 
fever,  and  milder  in  character.  Its  effects  upon  the  patient  may,  however, 
be  very  serious,  particularly  if,  as  sometimes  happens,  more  than  one 
relapse  takes  place ;  and  while  in  the  great  majority  of  instances  the 
termination  is  favourable,  death  may  occur  from  exhaustion,  haemorrhage, 
or  perforation.  The  cause  of  such  relapses  appears  to  be  a  reinfection  of 
the  system  from  the  primary  attack,  and  the  anatomical  changes  in  the 
intestine  reveal  the  presence  of  fresh  ulcers  affecting  glandular  tissue  which 
had  previously  escaped. 

Varieties  of  typhoid  fever. — Typhoid  fever  presents  such  differences 
in  character,  as  regards  severity,  duration,  modifications  resulting  from  age, 
climate,  and  other  conditions,  that  it  is  quite  possible  to  recognise  certain 
clinical  types  or  varieties.  Elaborate  divisions,  founded  largely  upon  the 
prominence  of  certain  symptoms,  have  been  made,  but  such  classifications 


TYPHOID  FEVER. 


are  of  little  value  for  clinical  purposes,  and  are  confusing.  ProbaLly  all 
the  various  forms  in  which  typhoid  fever  is  met  with  might  be  included 
under  the  following  classes : — 

The  milder  forms. — These  embrace — (a)  Cases  in  which  the  whole 
course  of  the  disease  from  its  onset  is  of  benign  character,  none  of  the 
symptoms  assuming  any  special  prominence,  and  convalescence  being 
established  in  less  than  four  weeks,  (b)  Cases  which  prove  abortive,  in 
which  the  characteristic  features  of  the  fever  are  present  but  are  of 
moderate  intensity,  and  come  to  an  abrupt  termination  in  from  one  to  two 
weeks.  It  is  probable  that  the  pathological  changes  in  the  intestine  are 
limited  to  infiltration  of  the  glandular  structures,  which  terminates  in 
resolution,  and  that  the  usual  ulceration  does  not  take  place,  (c)  The 
latent  or  ambulatory  form,  in  which  the  patient,  while  suffering  from  the 
fever,  continues  to  go  about.  This  type  of  fever  is  as  a  ride  mild,  but 
special  dangers  attend  its  non-recognition,  partly  from  the  possibility  of 
conveying  the  disease,  but  more  particularly  from  the  fact  that  such  cases, 
being  untreated,  the  risks  of  serious  symptoms,  such  as  haemorrhage  or 
perforation  suddenly  arising,  are  great,  (d)  Under  this  class  might  also 
be  included  the  occasionally  occurring  afebrile  forms  of  typhoid. 

The  graver  forms. — 
These  include — (a)  Cases  in 
which  all  the  symptoms  are 
severe  throughout — high  tem- 
perature, diarrhoea,  tympan- 
ites, delirium.  Such  cases  are 
apt  to  be  complicated  by 
haemorrhage  and  by  relapses, 
and  the  mortality  is  high. 
(b)  Cases  in  which  certain 
classes  of  symptoms,  not 
necessarily   belonging   to    the 

e.g. 
the 


fever,  are  prominent, 
pulmonary  symptoms,  in 
form  of  bronchitis  and  pneu 
monia  ;  nervous  symptoms,  FlG'  10-~A  mild  or  abortive  case  of  ^Phoid  fever' 
such  as  severe  headache,  suggestive  of  meningitis ;  urinary  symptoms,  in  the 
form  of  acute  nephritis ;  gastric  and  biliary  symptoms,  such  as  vomiting 
and  jaundice.  Such  accompaniments  may  not  only  form  complications 
more  or  less  serious,  but  they  often  mask  for  a  time  the  true  nature  of  the 
disease,  (c)  Cases  of  malignant  type,  such  as  occur  in  all  fevers,  in  which 
haemorrhage  from  mucous  surfaces,  extravasations  into  the  tissues  occur, 
and  those  in  which  the  symptoms  from  the  first  are  intensely  severe,  and 
bring  about  rapid  prostration  and  death. 

Typhoid  fever  in  early  and  in  later  life. — (a)  In  children,  before  the 
age  of  5,  typhoid  fever,  although  not  unknown,  is  uncommon;  but  it 
occurs  with  increasing  frequency  between  5  and  14.  Its  early  recogni- 
tion is  sometimes  a  matter  of  difficulty,  in  consequence  of  the  frequent 
presence  of  head  and  other  symptoms,  which  are  apt  to  simulate  tuber- 
culous meningitis.  There  are  certain  points  in  which  typhoid  fever  in 
the  child  differs  from  that  in  the  adult.  Its  course  upon  the  whole  is 
milder,  and  although  the  temperature  may  be  high,  it  has  throughout  a 
marked  tendency  to  remission,  which  led  formerly  to  this  disease  being 
included  under   the   general  term   infantile  remittent  fever.      The  rose- 


Day  of 
Disease 

5 

e 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

C. 
-40 

-39° 

•38° 

37° 

F. 
104 

103° 

102° 

101° 

100° 

99 
98 

A 

/ 

it 

s/ 

„   .   M 
Pulse 

E 

no/ 

/llO 

oe/ 

/1 00 

00/ 

I  00 

00/ 

/oo 

88/ 

/I00 

ac/ 

'  00 

oe/ 

7  9  6 

B*/ 

/p.  6 

92/ 

'  92 

1.2 
,/92 

00 

■    04 

80/ 
/84 

Motions 

0 

0 

I 

0 

I 

0 

2 

1 

0 

1 

1 

o 

134  GENERAL  DISEASES. 

coloured  spots  are  frequently  absent,  and  even  when  present  are  apt  to  be 
few  in  number.  The  intestinal  lesions  are  less  severe,  the  glandular 
structures  in  the  mucous  membrane  of  the  ileum  being  merely  infiltrated 
and  not  ulcerated,  at  least  in  young  children ;  and  while  diarrhoea  is 
common  enough,  haemorrhage  and  perforation  are  extremely  rare.  The 
mesenteric  glands  are  liable  to  be  engaged,  simulating  tabes  mesenterica. 
The  course  of  the  fever  is  comparatively  short,  but  relapses  are  frequent. 
The  death  rate,  however,  is  low.  (b)  Typhoid  fever  late  in  life  is  occasion- 
ally met  with,  notwithstanding  it  is  well  known  to  be  rare  after  40.  Well- 
marked  cases  have  been  described  in  persons  over  60,  70,  and  80.  The 
fever  tends  to  be  of  adynamic  type,  and  although  apparently  mild  as 
regards  temperature,  is  apt  to  be  protracted,  and  during  its  continuance 
exhaustion  or  collapse  are  to  be  feared.     The  death  rate  is  high. 

In  tropical  countries,  typhoid  fever,  although  differing  in  no  material 
respects  from  the  disease  in  temperate  climates,  has  a  more  serious  signi- 
ficance, and  the  mortality  is  greater.  The  conditions  of  the  temperature 
of  the  air  are  apt  to  accentuate  the  depressing  effects  of  the  fever. 

Sequelae — Not  a  few  of  the  conditions  already  referred  to,  as  compli- 
cations occurring  during  the  progress  of  a  case  of  typhoid  fever,  may  be  met 
with  during  or  after  convalescence  as  sequelae.  The  swelled  leg  is  one 
illustration  of  this ;  parotitis  is  another.  Periostitis,  affecting  for  the  most 
part  the  shafts  of  long  bones  in  adolescents,  is  a  well-recognised  occasional 
sequel  of  typhoid.  Although  as  a  rule  passing  off  soon,  in  some  cases  an 
abscess  forms,  and  necrosis  or  caries  of  the  bone  may  remain.  Abscesses 
may  occur  in  the  viscera ;  even  in  the  brain. 

The  health  may  be  affected  in  various  ways,  as  the  result  of  an  attack 
of  typhoid  fever.  Thus,  as  regards  the  digestive  system,  a  chronic  condition 
of  dyspepsia  may  long  persist,  probably  for  the  most  part  intestinal  in 
character,  and  obviously  admitting  of  ready  explanation  from  the  lesion  of 
the  bowels.  As  regards  the  respiratory  system,  phthisis  is  an  occasional 
though  apparently  not  very  frequent  sequel  of  typhoid  fever.  The  nervous 
sequelae  are  important,  and  include  many  forms  of  functional  disturbance, 
such  as  hysterical  conditions,  the  so-called  "typhoid  spine."  But  even 
insanity  may  follow  this  fever,  as  it  sometimes  follows  typhus.  Happily,  as 
in  the  latter,  the  prognosis  is  good.  A  few  cases  of  hemiplegia,  with  or 
without  aphasia,  have  been  reported. 

Diagnosis. — While  in  a  certain  number  of  cases  of  typhoid  fever  a 
diagnosis  is  readily  arrived  at,  it  is  frequently  almost  impossible  to  come  to  a 
definite  conclusion.  The  disease  has  no  single  pathognomonic  symptom,  and 
we  must  depend  on  the  concurrence  of  several  signs  and  symptoms,  no  one  of 
which  is  invariably  present  in  the  course  of  the  fever.  Owing  to  the  typically 
insidious  onset,  a  definite  diagnosis  can  seldom  be  made  in  the  first  week. 

The  history  of  the  patient  should  be  carefully  analysed.  Malaise, 
nausea,  headache,  and  insomnia  are  frequently  complained  of.  If,  in 
addition  to  these  symptoms,  the  patient  has  suffered  from  diarrhoea  or  from 
epistaxis,  and  the  temperature  is  found  on  examination  to  be  elevated, 
there  is  a  strong  presumption  that  the  case  is  one  of  typhoid  fever.  Sore 
throat  or  bronchial  catarrh  are  occasionally  the  symptoms  for  which  the 
patient  first  seeks  relief.  In  other  instances  the  complaint  is  of  loss  of 
appetite  and  indigestion,  and  the  heavily  furred  tongue  may  suggest  a 
gastric  catarrh.  If  such  a  case  does  not  improve,  under  appropriate  treat- 
ment, the  temperature  should  always  be  taken,  and  it  may  be  found  that 
the  catarrh  is  due  to  the  febrile  disturbance  caused  by  the  disease. 


TYPHOID  FEVER.  135 

The  physiognomy  of  the  patient  may  also  afford  assistance.  The  com- 
plexion is  usually  clear,  and  a  pink,  hectic-looking  flush  may  be  noticed  on 
the  cheek  bones.  The  pupils  of  the  eyes  are  larger  than  normal,  and  this 
gives  the  patient  the  expression  of  languor  and  ennui  which  is  nearly 
always  present  in  a  true  case. 

If  the  case  is  seen  during  the  first  few  days  of  the  illness,  the  curve  of 
the  temperature  should  be  carefully  watched.  A  case  which  shows  a 
temperature  of  104°  on  the  first  day  of  the  disease  is  almost  certainly  not 
typhoid  fever.  On  the  other  hand,  a  step-like  rise  of  the  evening  tempera- 
ture, with  slight  morning  remissions  for  the  first  four  or  five  days,  is  very 
suspicious. 

The  pulse  is  accelerated,  but  seldom  in  proportion  to  the  rise  of 
temperature.  This  sign  is  of  great  value  in  making  a  diagnosis.  In  an 
adult  it  should  average  from  90  to  100,  and  even  in  children  it  is  slower 
than  would  be  expected.  After  the  first  week  dicrotism  is  almost  invari- 
ably present,  and  the  pulse  is  soft. 

The  presence  of  spots  about  the  seventh  or  eighth  day  of  a  continued 
fever  makes  the  diagnosis  almost  certain.  Their  absence,  however,  is 
unfortunately  of  no  diagnostic  value.  They  probably  usually  occur,  but 
in  mild  cases  they  have  frequently  disappeared  before  the  patient  comes 
under  notice. 

The  tumidity  of  the  abdomen  is  of  great  importance.  In  the  vast 
majority  of  cases  this  sign  is  present,  though  here  again  its  absence  does 
not  preclude  the  existence  of  the  disease.  There  is  usually  tenderness 
on  gentle  palpation  in  the  right  iliac  fossa.  Great  stress  has  been  laid  on 
gurgling  in  this  situation ;  but,  apart  from  the  fact  that  this  sign  can  often 
be  found  in  cases  of  ordinary  diarrhoea,  the  pressure  required  to  elicit  it  is 
hardly  advisable,  unless  it  is  absolutely  certain  that  the  fever  is  only  a 
week  old. 

Enlargement  of  the  spleen  is  invariable.  This  can  usually  be  made  out 
quite  satisfactorily  by  percussion,  but  often,  especially  in  children,  the 
organ  can  be  quite  readily  palpated. 

Ochre-coloured  "  pea  soup "  stools  should  always  cause  a  suspicion  of 
typhoid  fever,  but  it  must  be  remembered  that  such  stools  may  occur  in 
other  diseases,  in  which  a  patient  with  high  temperature  has  been  fed  on 
more  milk  than  he  can  digest.  "We  may  here  add  that  the  occurrence  of  a 
haemorrhage  in  a  case  with  continued  fever  gives  an  almost  certain 
diagnosis. 

The  palmar-plantar  sign  of  Filipovitch  has  recently  attracted  consider- 
able attention.  It  consists  in  a  saffron-yellow  coloration  of  the  hard  skin 
of  the  palms  and  soles.  While  it  certainly  is  very  frequently  present  in 
adult  patients  with  hard  hands  and  feet,  we  have  not  noticed  it  so  often  in 
children,  and  it  has  been  noticed  in  other  diseases,  particularly  in  tubercu- 
losis. It  is  probably,  therefore,  of  no  great  value.  We  may  here  add  that 
marked  desquamation  may  often  be  seen  on  the  feet. 

Bacteriological  diagnosis. — 1.  Examination  for  the  bacillus  of  Eberth. 
— As  has  been  already  hinted,  the  great  difficulty  of  isolating  this 
bacillus  places  this  method  of  diagnosis  out  of  the  reach  of  all  but  expert 
bacteriologists.  During  the  first  week  of  the  fever  there  is  a  fair  chance. of 
getting  a  successful  cultivation  from  the  stools ;  but  as  several  days  are 
required  to  distinguish  the  organism  from  the  B.  coli  communis,  the  case 
will  in  most  cases  have  declared  itself  before  a  definite  opinion  can  be 
given.     Puncture  of  the  spleen  to  obtain  the  bacillus  is  more  likely  to  give 


136  GENERAL  DISEASES. 

a  pure  cultivation  at  once,  but  even  those  who  have  introduced  and  used 
this  method  with  success  hesitate  to  recommend  a  procedure  which  can 
hardly  be  free  from  risk. 

2.  WidaVs  serum  reaction. — Of  much  greater  value  than  the  above  test 
is  serum  diagnosis.  Introduced  almost  simultaneously  in  the  summer  of 
1896  by  Widal  and  Grunbaum,  it  has  already  taken  a  high  place  in  the 
diagnosis  of  typhoid  fever.  The  test  depends  on  the  behaviour  of  the 
bacillus  of  Eberth,  when  exposed  to  the  blood  of  a  patient  suffering  from 
the  fever.  In  such  a  medium  the  bacilli,  previously  motile  and  evenly 
diffused  over  the  microscopic  field,  lose  this  motility  and  agglutinate  into 
masses  or  clumps.  In  blood  from  normal  persons,  or  from  patients  suffering 
from  other  diseases,  the  bacilli  remain  active,  and  the  reaction  does  not 
occur.  As  the  successful  performance  of  this  test  requires  an  incubator  in 
which  to  make  the  necessary  cultures,  it  is  hardly  likely  to  be  of  much  use 
to  the  general  practitioner.  But  in  hospitals  it  can  be  readily  managed, 
and  public  laboratories  have  in  many  instances  made  arrangements  to  test 
blood  sent  to  them.  The  method  we  have  found  most  useful  in  hospital 
practice  is  as  follows  : — 

The  stock  cultures  of  the  bacillus  are  kept  on  agar  or  gelatin  at  the 
temperature  of  the  room.  The  night  before  a  test  is  required,  a  subculture 
is  made  on  agar  and  incubated  at  37°  C.  The  next  day  the  culture  has 
grown  sufficiently  for  a  platinum  loopful  to  be  scraped  from  it.  This  is 
stirred  into  a  few  drops  of  sterilised  beef  bouillon  in  a  watch-glass,  and  it 
is  with  the  emulsion  of  bacilli  so  procured  that  the  test  is  performed.  The 
thumb  of  the  patient  is  carefully  cleansed,  and  is  pricked  just  above  the 
nail.  The  blood  is  drawn  up  in  an  ordinary  leucocytometer  pipette  to  the 
mark  just  below  the  bulb.  The  point  of  the  pipette  is  then  wiped,  and 
sterilised  beef  bouillon  sucked  up  till  the  bulb  is  filled,  and  the  instrument 
is  then  shaken.  The  pipette  now  contains  1  part  of  blood  to  10  of 
bouillon.  The  mixture  is  then  ejected  into  a  U-shaped  tube,  previously 
bent  for  the  purpose  in  a  Bunsen  flame,  and  the  tube  is  placed  in  a  centri- 
fuge. This  brings  the  corpuscles  down  into  the  bend  of  the  tube,  leaving 
clear  serum  above.  The  centrifuging  process  need  not  be  very  complete, 
as  a  few  blood  corpuscles  greatly  assist  the  ready  focussing  of  the  micro- 
scope afterwards.  Two  drops  of  this  diluted  serum  mixed  on  a  celled  slide, 
with  one  drop  of  the  emulsion  from  the  watch-glass,  give  a  mixture  consist- 
ing of  a  somewhat  indefinite  number  of  bacilli  moving  in  a  medium  con- 
sisting of  1  part  of  blood  to  30  of  sterile  bouillon.  The  slide  is  then 
examined  under  an  ordinary  high  power. 

If  the  blood  be  that  of  a  typhoid  patient,  the  bacilli,  at  first  actively 
motile,  are  seen  gradually  to  lose  their  activity.  They  cease  to  move 
rapidly  across  the  field,  sometimes  spin  rapidly  on  their  own  axis,  and 
begin  to  show  a  tendency  to  stick  to  each  other.  First  merely  stuck 
together  in  twos  and  threes,  these  small  groups  become  joined  to  each  other, 
till,  after  a  period  varying  from  a  few  minutes  to  several  hours,  the  micro- 
scope field  presents  two  or  three  large  colourless  masses,  consisting  of 
immotile  bacilli,  and  a  space  perfectly  free  from  moving  bacilli  between 
these  clumps.  In  a  certain  proportion  of  cases  the  clumps  may  be  joined 
to  each  other  by  long  strings  of  motionless  bacilli,  giving  a  "  reticulate  " 
appearance  to  the  reaction.  The  reaction  should  be  practically  complete 
in  four  hours  to  be  regarded  as  final. 

Another  method,  recommended  by  Delepirte,  of  working  this. test,  is  to 
draw  the  blood  from  the  patient  into  a  capillary  glass  tube,  provided  with 


TYPHOID  FEVER.  137 

a  small  bulb.  Tbe  ends  are  sealed  in  a  flame,  and  the  blood  can  be  kept 
an  indefinite  period,  and  can  be  very  easily  sent  to  a  laboratory  by  post. 
In  making  the  dilution,  a  loopful  of  the  clear  serum,  which  has  separated 
from  the  clot,  is  placed  on  a  coverslip,  and  ten  or  fifteen  loopfuls  of  a 
fresh  culture  (made  in  bouillon)  are  added  and  mixed.  The  coverslip  can 
be  then  inverted  on  an  ordinary  slide. 

A  third  method,  that  of  Wright,  depends  on  the  fact  that  if  the  mixture 
of  serum  and  culture  is  sucked  up  into  a  slender  glass  tube,  and  the  tube 
left  standing  erect  in  a  rack,  the  masses  of  agglutinated  bacilli  sink  to  the 
bottom  of  the  tube,  and  form  a  little  white  plug  or  sediment  which  can  be 
easily  seen  by  the  naked  eye.  This  "  sedimentation  "  test  is  particularly 
useful  in  laboratories,  where  large  numbers  of  specimens  have  to  be 
examined.  Tubes  containing  normal  blood  show  merely  an  evenly  diffused 
cloudiness. 

In  performing  the  test  satisfactorily,  there  are  several  important  points 
to  attend  to.  First,  the  subculture  must  not  be  more  than  twenty-four 
hours  old.  Cultures  of  a  longer  date  are  not  nearly  so  motile,  and  occa- 
sionally show  masses  which  may  readily  be  mistaken  for  true  clumps. 
Second,  it  is  advisable  to  always  return  to  the  original  stock  cultures 
when  a  subculture  is  required,  as,  if  there  is  too  much  subcultivating,  the 
cultures  appear  to  become  attenuated.  Third,  the  dilution  should  not 
be  less  than  1  part  of  blood  to  25  of  bouillon,  as  occasionally  healthy 
blood  gives  a  reaction,  if  the  dilution  is  insufficient.  Fourth,  either  the 
culture  should  be  carefully  examined  under  the  microscope,  before  per- 
forming the  test,  to  see  that  it  is  active  and  does  not  contain  false  clumps, 
or,  what  is  still  better,  a  normal  blood,  and,  if  possible,  the  blood  of  a 
known  typhoid  patient,  should  always  be  examined  together  with  the  new 
specimen,  so  as  to  give  a  check  to  the  results.  Should  these  precautions 
be  taken,  there  will  be  wonderfully  few  anomalous  results. 

As  regards  the  rationale  of  this  test,  it  has  been  suggested  that  there 
are  developed  in  the  blood  of  typhoid  patients  certain  substances  which 
have  been  termed  agglutinins.  These  substances  have  some  chemical  or 
physical  action  on  the  protoplasm  or  sheath  of  the  bacillus,  and  so  cause 
the  reaction.  They  appear  to  use  themselves  up  in  the  process,  which 
would  account  for  partial  reactions  taking  place,  should  the  bacilli  be  too 
numerous.  Whether  the  action  implies  immunity  is  a  question  of  some 
doubt.  It  occasionally  lasts  many  years  after  a  patient  has  had  the  fever. 
It  also  appears  in  the  blood  of  persons  vaccinated  by  injections  of  dead 
bacilli.  In  the  meantime  we  may  say  that  its  presence  certainly  does  not 
prevent  relapses,  which  should  be  to  a  certain  extent  an  argument  against 
it  as  a  proof  of  immunity.  Perhaps  it  is  safer  at  present  to  regard  it  as  a 
reaction  of  infection. 

As  regards  the  value  of  the  test,  its  presence  implies  that  a  patient  is 
either  suffering  from  typhoid  fever,  or  has  had,  at  some  time  or  other, 
typhoid  fever.  Its  absence  unfortunately  cannot  be  held  to  prove  that 
the  disease  is  not  typhoid,  as  has  been  proved  more  than  once  both 
pathologically  and  bacteriologically.  It  is  occasionally  disappointing  in 
that  it  may  not  appear  till  later  on  in  the  fever,  when  all  difficulty  has 
probably  disappeared;  and  it  is  quite  common  to  fail  to  get  it  before  the. 
second  week.  In  our  experience,  however,  it  is  by  far  the  most  accurate 
method  at  our  disposal  for  the  diagnosis  of  typhoid  fever. 

Differential  diagnosis.— While  in  making  a  diagnosis  attention  to 
the  principles  mentioned  above  is  usually  sufficient,  it  will  be  useful  to 


GENERAL  DISEASES. 


remember  the  characteristics  of  the  diseases  most  likely  to  be  confused 
with  typhoid  fever.  Of  these  the  following  are  perhaps  the  most 
important : — 

Typhus  fever. — On  inquiring  into  the  history,  if  it  is  found  that  the 
patient  was  suddenly  attacked,  and  can  point  to  a  sudden  rigor  or  to 
marked  prostration  from  the  first  day  of  his  illness,  it  is  much  more 
probable  that  we  are  dealing  with  a  case  of  typhus.  On  the  other  hand, 
if  there  is  a  history  of  more  than  a  fortnight's  fever,  the  disease  is  more 
likely  to  be  typhoid,  since  typhus  terminates  by  crisis  about  the  four- 
teenth day.  We  may  tabulate  the  main  distinctions  between  the  diseases 
as  follows : — 


Typhoid  Fever. 

Typhus  Fever. 

Face 

Pale  with  hectic  flush. 

Congested  and  bloated. 

Expression- 

Languid  and  apathetic. 

Drunken. 

Pupils 

Dilated,  or  in  bad  cases  normal. 

Contracted  almost  invariably. 

Conjunctiva  . 

Clear. 

Injected. 

Abdomen 

Tumid  and  tender. 

Usually  normal  and  not  tender. 

Rash 

Rose  spots  fading  on  pressure. 

Petechia  from  seventh  day. 

Pulse 

Usually,  even  in  bad  cases,  in- 
frequent. 

Rapid. 

Termination  . 

By  lysis. 

By  crisis. 

In  addition  to  these  differences,  we  may  add  that  diarrhoea  is  not 
common  in  typhus,  except  occasionally  about  the  time  of  the  crisis.  The 
spleen  is  usually  enlarged  more  or  less  in  typhus,  and  therefore  much  stress 
cannot  be  laid  on  its  size.  The  temperature,  moreover,  in  bad  cases  of 
typhoid  may  show  very  little  of  the  characteristic  morning  remission,  but 
may  continue  in  almost  a  straight  line  on  the  chart.  And,  lastly,  a  dirty 
iiea-bitten  skin  in  a  typhoid  patient  may  have  a  striking  resemblance  to  a 
badly  developed  typhus  rash. 

Tuberculosis — (a)  Tuberculous  meningitis. — This  is  only  likely  to  be  con- 
fused with  cases  of  typhoid  fever  with  marked  head  symptoms.  In  such 
cases  the  temperature  is  usually  high,  probably  about  104°,  and  the 
moderately  slow  pulse  of  typhoid  is  usually  accelerated.  In  tuberculous  men- 
ingitis the  fever  is  as  a  rule  moderate  and  more  hectic  in  type,  and  the  pulse 
may  in  certain  cases  be  less  frequent  than  normal.  The  pupils,  moreover, 
instead  of  being  equally  dilated,  are  often  unequal,  and  squinting  is  common. 
An  ophthalmoscopic  examination  may  discover  miliary  tubercles.  There  is 
no  rash  on  the  abdomen,  and  the  tache  cerebrale  can  be  elicited.  The 
spleen  as  a  rule  is  not  enlarged  and  the  abdomen,  so  far  from  being  tumid, 
is  in  most  cases  retracted  or  "  scaphoid."  Vomiting,  rare  in  typhoid  fever, 
is  not  unusual  in  tuberculous  meningitis.  It  has  further  been  pointed  out 
by  Jenner,  that  in  typhoid  fever  the  headache  ceases  when  the  delirium 
begins.  Lastly,  the  family  history,  the  presence  or  absence  of  pulmonary 
lesions,  and  the  question  of  possibilities  of  infection,  may  all  throw  light  on 
a  doubtful  case. 

(3)  Still  more  difficult  is  the  diagnosis  from  early  cases  ol  tuberculous 


TYPHOID  FEVER.  139 

'peritonitis.  The  appearance  of  a  patient  suffering  from  this  disease  may 
closely  simulate  that  of  a  typhoid  case.  The  tumid  abdomen,  before 
glandular  masses  are  palpable  or  fluid  can  be  detected,  may  also  be  puzzling. 
But  the  presence  of  either  of  these  signs  will  clear  up  the  case.  The 
temperature  of  typhoid  fever  never  falls  while  the  abdomen  remains 
distended ;  that  of  a  tuberculosis  may  do  so. 

(y)  Acute  tuberculosis  has  also  frequently  been  mistaken  for  typhoid 
fever.  The  onset  in  this  disease  is  more  gradual,  and  the  wasting  as  a 
rule  greater.  If  the  lungs  are  severely  affected,  the  microscopic  examina- 
tion of  the  sputum  for  bacilli  may  settle  the  point.  Again,  the  breathing 
is  more  rapid  and  the  face  more  cyanosed,  and  sweating  is  more  frequent. 
But  in  some  cases  it  may  be  said  that  a  diagnosis  cannot  be  made,  and  we 
are  reduced  to  considering  the  family  history,  and  waiting  for  further 
developments  before  giving  a  definite  opinion.  It  is  particularly  in  these 
obscure  tuberculous  cases  that  we  have  found  the  Widal  reaction  most 
useful. 

Pulmonary  inflammations. — Pneumonias  are  very  often  mistaken  for 
typhoid  fever.  Out  of  169  consecutive  cases  sent  in  to  the  Edinburgh 
City  Hospital  as  the  latter  disease,  no  fewer  than  sixteen  were  the  subjects 
of  pneumonia  only.  At  first  sight  it  would  seem  that  it  needs  considerable 
carelessness  to  make  such  an  error,  but  the  physical  signs  of  lung 
inflammations,  especially  in  children,  are  sometimes  so  obscure  that  the 
mistake  is  readily  made. 

(a)  Acute  lobar  pneumonia  is  usually  detected  by  the  rapidity  of  the 
respiration,  although  occasionally  its  rate  may  be  only  slightly  accelerated. 
After  a  day  or  two  the  case  usually  declares  itself,  as  consolidation  becomes 
more  marked,  but  even  then  it  is  difficult  to  decide  if  the  lung  condition  is 
not  merely  a  complication  of  a  typhoid  fever.  The  difficulty  is  increased 
in  cases  where  head  symptoms  and  delirium  are  marked,  and  sometimes 
the  occurrence  of  the  crisis  is  required  to  make  a  definite  diagnosis. 
Herpes  of  the  lips,  so  common  in  pneumonia,  is  very  rare  in  typhoid,  and  its 
existence  would  point  to  the  case  being  one  of  the  former  disease.  The 
pulse  also  of  pneumonia  is  frequent. 

(|8)  Catarrhal  pneumonia  in  children  is  frequently  attended  with 
symptoms  which  may  suggest  typhoid  fever.  The  digestion  is  often 
disturbed,  and  this  may  lead  to  abdominal  distension  and  severe  diarrhoea. 
Careful  daily  examination  of  the  chest  will,  however,  usually  decide  the 
case,  but  where  the  patches  of  inflammation  are  very  small  it  may  be  some 
days  before  a  diagnosis  can  be  made. 

Influenza. — It  is  only  the  gastro-intestinal  form  of  this  fever  which  is 
liable  to  be  confused  with  typhoid  fever.  The  chief  points  to  be  noted 
are,  the  comparatively  sudden  onset  of  influenza,  its  characteristic  pains 
in  the  back,  and  the  frequent  limitation  of  its  headache  to  the  frontal 
region.  The  subsidence  of  the  fever  in  the  second  week  will  also  point 
to  influenza.  It  must,  however,  be  remembered  that  the  two  diseases  may 
exist  together. 

While  the  diseases  mentioned  above  are  of  most  importance,  it  is  well 
to  bear  in  mind  that  typhoid  fever  is  also  simulated  by  certain  cases  of 
ulcerative  endocarditis,  gastro-enteritis,  trichiniasis,  relapsing  fever,  and 
appendicitis ;  also  by  the  fever  which  attends  the  secondary  manifestations 
of  syphilis.  On  the  other  hand,  the  occurrence  of  an  erythematous  rash 
and  sore  throat,  at  the  outset,  may  lead  to  a  diagnosis  of  scarlatina. 

Prognosis. — Every  case  of  typhoid  fever,  however  mild,  is  liable  to 


i4o  GENERAL  DISEASES. 

serious  complications  and  sequelae,  and  therefore  the  prognosis  will  always 
be  carefully  guarded.  The  longer  a  patient  has  been  struggling  against 
giving  in  to  the  disease  and  taking  to  his  bed,  the  worse  become  his 
chances  of  recovery. 

Epidemics  vary  considerably  in  severity,  and  much  stress  cannot 
therefore  be  laid  on  the  percentage  mortality  of  the  disease,  which  may 
vary  from  7  to  20  under  different  circumstances.  Occasionally  an 
epidemic  occurs,  where  all  the  cases  are  marked  by  severe  symptoms. 
Again,  certain  persons  appear  to  be  constitutionally  susceptible  to  the 
fever,  and  the  type  may  be  more  severe  in  certain  families  than  it  is  in 
others.  It  is  said,  on  apparently  sound  statistical  evidence,  that  females 
have  a  higher  death  rate  than  males,  1  per  cent,  more  of  those  attacked 
succumbing  to  the  disease. 

Putting  aside  these  more  general  considerations,  it  may  be  broadly 
said  that  the  prognosis  becomes  progressively  more  serious  as  age 
increases.  Children,  in  the  vast  majority  of  cases,  do  well.  In  older 
persons,  and  especially  in  the  middle-aged,  the  outlook  is  worse. 

The  conditions  which  justify  a  favourable  prognosis  are  the  following : — 
Moderate  fever,  not  exceeding  103°  F.  at  night,  and  characterised  by 
considerable  morning  remission ;  a  pulse  not  exceeding  100  in  the  adult, 
or  120  in  the  child;  a  moist  and  not  heavily  coated  tongue;  a  soft  and 
slack  abdomen ;  and  an  absence  of  complications.  If,  moreover,  the 
patient  sleeps  well,  and  can  move  himself  freely  in  bed,  a  favourable 
termination  may  be  expected  with  some  confidence.  But  it  must  always 
be  remembered  that  the  mildest  cases  may  suffer  from  haemorrhage  or 
perforation,  and  it  is  advisable  not  to  admit  that  they  are  out  of  danger 
till  the  evening  temperature  has  been  ten  days  normal  at  least. 

If,  on  the  other  hand,  the  patient  is  alcoholic,  if  he  suffers  from 
insomnia,  delirium,  or  subsultus  tendinum,  and  if  he  lies  on  his  back 
unable  to  turn  in  bed,  the  prognosis  is  distinctly  unfavourable.  Vomiting, 
retention  of  urine,  incontinence  of  urine  or  faeces,  marked  and  persistent 
tympanites,  and  severe  diarrhoea  (ten  to  twelve  motions  daily),  are  of  very 
grave  import.  Again,  a  pulse  of  over  120  in  an  uncomplicated  adult 
case,  should  cause  anxiety.  If  the  pulse  in  such  a  case  reaches  130,  there 
is  reason  for  alarm.  As  regards  the  temperature,  a  persistent  level  at 
about  104°  F.,  or  over,  without  marked  morning  remission,  points  to  a 
severe  case.  If  this  temperature  is  maintained  in  the  third  week  of  the 
disease,  and  there  is  no  sign  of  a  lysis,  it  is  probable  that  the  case  will 
run  twenty-eight  days  at  least ;  and  if  other  of  the  unfavourable  signs 
mentioned  above  are  present,  the  prognosis  becomes  very  grave. 

While  spots  have  no  relation,  as  regards  their  number  or  presence,  to 
the  severity  of  the  case,  still  it  is  unusual  to  see  a  lysis  commence  as  long 
as  successive  crops  appear.  If,  as  has  been  suggested,  each  new  crop 
represents  a  further  invasion  of  hitherto  unaffected  Peyer's  patches  in  the 
intestine,  it  is  not  reasonable  to  expect  marked  improvement  in  a  bad  case 
as  long  as  they  continue  to  come  out. 

As  regards  the  occurrence  of  the  ordinary  complications  of  typhoid 
fever,  haemorrhage,  unless  it  occurs  in  the  first  ten  days  of  the  fever,  must 
always  be  regarded  as  serious,  especially  if  the  temperature  has  fallen 
considerably  and  declines  to  rise.  If,  however,  there  is  no  recurrence 
within  forty-eight  hours,  and  the  temperature  has  regained  its  original 
level,  the  patient  often  does  very  well,  and  sometimes  seems  none  the  worse 
for  the  accident. 


TYPHOID  FEVER.  141 

Perforation  is  practically  always  fatal.  »  Certain  cases  of  recovery,  by 
adhesive  peritonitis  having  limited  the  leakage,  and  of  successful  operative 
interference,  have  been  recorded.  But  at  present  it  is  safer  to  assume 
there  is  no  hope  in  such  a  case.  An  operation,  therefore,  would  always  be 
justifiable,  even  though  the  chance  of  success  is  infinitesimal. 

Kelapses  are,  as  a  rule,  milder  than  the  original  fever,  though  there  are 
exceptions  to  this  rule.  The  prognosis  is,  on  the  whole,  favourable.  They 
seldom  last  much  more  than  a  fortnight. 

Intercurrent  complications  make  the  outlook  much  more  serious. 
Pneumonic  complications  are,  in  our  experience,  exceedingly  fatal.  Eenal 
disease,  interfering  no  doubt  with  the  elimination  of  the  toxines,  is  of  grave 
import.  Pregnancy  is  nearly  invariably  fatal  to  the  child,  and  is  very 
dangerous  to  the  mother.  Typhoid  fever,  complicated  by  the  puerperal 
state,  is  also  very  serious. 

Treatment. — Under  this  head  will  be  embraced  the  prophylaxis,  the 
general  management  of  a  case  both  during  its  progress  and  in  con- 
valescence, and  the  measures  to  be  employed  for  dealing  with  special 
symptoms  and  complications. 

Prophylaxis. — This  subject  can  only  be  alluded  to  in  very  general 
terms.  Since  it  is  mainly  through  drinking  water  that  the  poison  of 
typhoid  fever  gets  access  to  the  body,  it  is  clear  that,  whether  in  large 
or  small  communities,  the  water  supply  should  be  secured  against 
contamination  by  sewage,  both  in  its  source  and  its  distribution.  This  is 
one  of  the  prime  duties  of  public  hygiene  on  the  part  of  local  authorities, 
and  the  neglect  of  it  has  been  followed  with  disastrous  consequences  in 
only  too  many  instances.  In  the  case  of  large  and  populous  centres, 
sanitary  arrangements  are  more  likely  to  be  under  immediate  supervision 
and  control  than  in  thinly  peopled  country  districts,  or  in  isolated  houses, 
where  the  water  supply  is  often  derived  from  wells  and  streams. 

One  of  the  most  efficient  of  all  prophylactic  measures  is  notification. 
Outbreaks  of  typhoid  fever  usually  make  themselves  manifest  at  first  as 
sporadic  cases,  or  as  localised  epidemics,  and  an  efficient  system  of 
notification  places  in  the  hands  of  public  medical  officers  the  means  for 
tracing  their  origin,  and  effectually  dealing  with  it. 

Nor  does  the  water  supply  alone  demand  careful  attention,  but  all 
matters  relating  to  drainage,  house  sanitation  (including  the  regular 
cleansing  of  cisterns  and  sinks),  as  well  as  cleanliness,  in  a  community, 
form  equally  important  considerations  in  respect  to  the  prevention  of 
typhoid  fever. 

When  a  case  occurs,  careful  inquiry  has  to  be  made  as  to  the  existence 
of  any  previous  case,  and  although  such  inquiries  are  often  enough  fruit- 
less, it  has  frequently  happened  that  outbreaks  have  been  clearly  traced  to 
their  origin,  Where  suspicion  attaches  to  drinking  water  or  to  milk,  these 
should  be  boiled  before  use.  Food  supplies  also  from  possible  sources  of 
contamination  should  be  avoided. 

The  disinfection  and  disposal  of  the  excreta  from  a  typhoid  patient  is 
a  matter  of  first  importance.  For  this  purpose  there  seems  to  be  no 
better  chemical  agent  than  carbolic  acid,  a  solution  of  which,  of  strength 
1  in  40  or  1  in  20,  should  be  added  to  the  stools  and  left  in  contact  with 
for  them  two  or  three  hours  before  they  are  disposed  of.  Other  disinfectants 
are  sometimes  employed,  such  as  corrosive  sublimate  (1  in  500,  slightly 
acidulated  with  hydrochloric  acid),  but  the  liability  of  most  of  them  to  act 
on   the   pipes  and  other  plumber  work  prevents  their   general  use  for 


142  GENERAL  DISEASES. 

dwelling-houses,  although  they  may  be  of  service  in  places  where  the 
excreta  are  disposed  of  in  pits  or  privies. 

All  utensils  and  vessels  should  be  washed  in  the  disinfecting  fluid  after 
being  used.  Bed  or  body  linen  soiled  with  the  stools  should  be  soaked 
in  carbolic  acid  solution,  or  boiled  before  being  washed.  Nurses  and 
attendants  should  cleanse  the  patient's  perineum  with  a  weak  carbolic  or 
corrosive  sublimate  solution,  after  stools  have  been  passed,  and  should  be 
scrupulously  careful  in  similarly  cleansing  their  own  hands,  which  may 
have  become  soiled  with  the  discharges. 

General  management. — The  general  management  of  a  patient  with 
typhoid  fever  bears  reference  for  the  most  part  to  efficient  nursing  and 
dieting.  The  patient  should  be  in  a  large,  airy,  and  well-ventilated 
room,  the  temperature  of  which  should  be  kept  at  about  60°  F.  There 
should  be  free  access  of  fresh  air  by  window  or  door,  in  such  a  way, 
however,  that  draughts  are  not  likely  to  be  felt  by  the  patient.  The 
bed  should  be  moderately  firm,  but  not  hard.  The  nurses  should  keep 
an  accurate  record  of  the  patient's  temperature  (which  should  be  taken 
every  four  hours,  or  oftener  if  required),  the  times  of  feeding,  the 
quantity  given,  and  the  amount  of  sleep;  and  also  note  carefully  any 
changes  in  the  patient's  symptoms  and  appearances  occurring  during 
the  absence  of  the  medical  attendant.  The  mouth  of  the  patient 
should  be  attended  to,  and  kept  clean  by  boric  solution  or  other  mild 
antiseptic,  and  the  whole  body  of  the  patient  should  be  sponged  daily. 
The  skin  should  be  kept  thoroughly  dry,  and  examined  particularly  at 
those  parts  where  pressure  bears,  and  the  patient's  position  changed  from 
time  to  time  to  obviate  the  occurrence  of  bed-sores.  The  patient  should 
not  be  moved  out  of  bed  at  least  after  the  first  week,  and  the  urinal  and 
bed-pan  should  be  employed.  Visitors  should  be  excluded,  and  the  patient 
kept  perfectly  quiet.  Milk  is,  by  almost  universal  consent,  held  to  be  the 
best  food  in  typhoid  fever,  and,  in  most  instances,  it  is  the  only  article  of 
diet  necessary  during  the  progress  of  a  case.  It  is  usually  taken  readily, 
even  by  those  to  whom  at  other  times  it  may  be  distasteful.  Much 
depends  upon  its  mode  of  administration.  It  should  not  be  given  too  often, 
nor  in  too  great  quantity.  About  4  oz.,  given  every  two  and  a  half  or 
three  hours,  will  probably  be  found  to  agree  well.  It  may  be  given  alone, 
or  diluted  with  a  small  amount  of  pure  water,  lime-water,  or  soda-water. 
The  total  quantity  given  in  twenty-four  hours  should  not,  as  a  rule,  exceed 
two  and  a  half  or  three  pints.  It  is  necessary  to  ascertain  whether  the 
milk  is  agreeing  with  the  patient  by  being  properly  digested.  The  stools 
must  accordingly  be  examined  regularly,  and  should  portions  of  undigested 
curd  be  found  to  any  extent,  the  use  of  milk  may  have  to  be  suspended  for 
a  time,  or  it  may  be  reduced  in  amount,  oi  diluted  or  peptonised.  Animal 
broths  or  jellies  may  be  substituted  for  a  time,  but  while  they  are  of 
undoubted  use  as  stimulants,  they  do  not  possess  the  nutritive  value  of 
milk.  Barley-water,  well  strained  oat-gruel,  white  of  egg,  thin  custard, 
etc.,  may  be  usefully  employed  during  the  time  the  milk  feeding  is  reduced 
or  suspended ;  but  care  has  to  be  taken  that  diarrhoea  is  not  induced  or 
aggravated  by  such  changes  in  diet.  The  food  should  be  administered 
both  by  day  and  night.  If  the  patient  be  unconscious,  he  must  be  roused 
to  take  the  food  at  the  regular  time.  On  the  other  hand,  when  he  is  in  a 
calm  sleep,  it  is  better  in  most  cases  not  to  disturb  him. 

Some  eminent  authorities  have  advocated  the  use  of  a  solid  diet  of  meat, 
and  have  shown  what  seemed  to  be  satisfactory  results.     But  this  plan  has 


TYPHOID  FEVER.  143 

never  been  extensively  adopted,  and  the  weight  of  opinion  is  altogether  in 
favour  of  the  practice  which,  recognising  in  typhoid  fever  a  condition  in 
which  the  whole  alimentary  canal  suffers  more  or  less  in  its  nutrition, 
adapts  the  dietary  of  the  patient  to  the  altered  digestive  and  assimilative 
functions.  Water  may  be  freely  administered,  but  the  amount  at  one 
time  should  be  moderate,  large  drinks  sometimes  tending  to  aggravate  the 
diarrhoea. 

Provided  the  food  is  agreeing,  no  change  should  be  made  in  the  patient's 
diet  during  the  progress  of  the  fever ;  but  when  the  temperature  becomes 
normal,  and  convalescence  seems  to  have  set  in,  a  little  more  substantial 
food  may  be  cautiously  introduced,  such  as  meat  broths  thickened  with 
rice  or  barley,  milk  puddings,  boiled  or  steamed  fish,  besides  tea  or 
coffee.  But  in  all  such  changes  made  in  the  diet  the  stools  should  be 
examined  to  see  that  the  food  has  been  digested.  At  the  same  time  the 
temperature  should  be  carefully  noted,  and,  should  any  material  rise  be 
observed,  a  return  to  the  fever  diet  must  be  made.  In  no  disease  has 
convalescence  to  be  more  carefully  watched. 

The  question  of  alcoholic  stimulants  in  typhoid  fever  has  been  much 
discussed,  and  different  views  are  held  and  given  effect  to.  It  is  certain 
that  all  cases  of  typhoid  do  not  require  alcohol,  and  that  probably  there  is 
a  tendency  to  err  in  the  direction  of  its  too  frequent  and  indiscriminate 
use.  Many  cases  of  moderate  severity  and  average  duration  never  present 
symptoms  calling  for  stimulation.  The  indications  for  alcohol  bear 
reference  to  the  effects  of  the  fever  upon  the  patient's  strength,  and  the 
evidence  derived  from  the  circulatory  and  nervous  symptoms.  Where  the 
heart,  as  a  result  of  long-continued  high  temperature  or  diarrhoea,  shows 
signs  of  feebleness,  in  a  weakened  first  sound  or  irregular  action,  and  a 
small  pulse,  along  with  evidences  of  pulmonary  congestion,  alcohol  may 
prove  of  signal  service;  so  also  when  symptoms  of  collapse  threaten. 
Alcohol  is  sometimes  highly  efficacious  in  procuring  sleep,  and  in  quelling 
the  restlessness  and  delirium  which  often  characterise  the  later  phases  of  a 
severe  attack  of  typhoid.  The  form  best  suited  for  administration  is  pure 
spirit  (brandy  or  whisky),  and,  as  regards  quantity,  no  general  rule  should 
be  laid  down ;  but  much  must  be  left  to  the  physician's  judgment  of  the 
requirements  of  the  case.  It  is  seldom  that  more  than  6  or  8  oz.  in 
twenty-four  hours  are  demanded,  and  care  should  be  taken  to  see  that  it 
fulfils  its  purpose,  since  it  may  happen  that  alcohol  may  be  found  to 
increase  the  patient's  restlessness,  and  thus  require  to  be  lessened  in 
amount  or  discontinued.  Other  cardiac  stimulants  and  tonics  may  some- 
times be  found  of  service,  along  with  or  in  place  of  alcohol,  such  as  ammonia, 
digitalis,  and  strychnine. 

Diarrhoea,  if  slight,  may  require  no  special  treatment,  but  in  many 
instances  this  symptom  assumes  such  proportions  as  to  call  for  remedies 
to  restrain  it.  Occasionally  some  change  in  the  feeding  may  suffice  to 
effect  this,  such  as  boiling  the  milk  and  adding  lime-water  or  a  little 
isinglass  to  it,  or,  as  before  mentioned,  by  suspending  milk  altogether  for  a 
short  time,  if  there  is  reason  to  believe  that  the  diarrhoea  is  aggravated  by 
undigested  curd.  Enemata  of  starch,  with  or  without  laudanum,  are 
sometimes  efficacious.  Opium  or  Dover's  powder,  in  combination  with 
bismuth,  is  one  of  the  most  soothing  astringents.  A  mixture  containing 
acetate  of  lead  and  morphine,  the  lead  suppository,  the  mineral  acids,  tannic 
acid,  pernitrate  of  iron,  etc.,  may  often  be  found  of  use.  In  the  case  of 
children,  simple  starch  enemata,  chalk  mixture,  or  the  aromatic  powder 


i44  GENERAL  DISEASES. 

of  chalk  with  opium,  are  among  the  safest  remedies.  Meteorism  may 
occasionally  be  relieved  by  the  rectal  tube,  or  by  the  administration  of 
charcoal,  salol,  or  salicylate  of  bismuth.  Turpentine  in  doses  of  20  minims 
has  been  employed  with  success,  and  its  external  application  in  the  form  of 
a  stupe  is  useful.  A  light  application  of  ice  over  the  abdomen  is  sometimes 
followed  with  marked  benefit. 

Constipation,  which  may  exist  throughout  the  whole  duration  of  a  case, 
is  best  treated  by  a  small  dose — a  teaspoonful  or  less — of  castor-oil,  or  by 
an  enema  every  three  or  four  days.  The  former  is  probably  the  better 
method.  Saline  purgatives,  as  recommended  by  some,  are  not  free  from 
risk. 

Abdominal  pain,  which  is  occasionally  a  troublesome  symptom,  and 
may  sometimes,  though  not  always,  be  due  to  a  localised  peritonitis,  is 
relieved  by  warm  opium  fomentations,  or  by  a  light  ice-bag,  and  by  opium 
or  Dover's  powder  internally. 

Haemorrhage  is  best  treated  by  keeping  the  patient  entirely  at  rest. 
Morphine  is  the  most  useful  drug  to  effect  this,  and  may  be  given  in  the 
dose  of  25  or  30  minims  of  the  liquor,  followed  by  10-minim  doses  every 
two  or  four  hours  as  required.  The  feeding  must  be  reduced  to  the  lowest 
possible  limit,  a  little  milk  being  given  occasionally  in  quantities  not 
exceeding  a  tablespoonful  at  a  time.  Of  styptic  remedies,  acetate  of  lead 
{2\  grs.  every  four  hours),  or  turpentine  (20  minims  every  two  hours),  are 
probably  the  most  satisfactory.  If  there  is  no  further  motion,  the  bowels 
can  be  left  alone  for  three  or  four  days,  when  an'  olive-oil  enema  may  be 
given. 

Perforation  has  unfortunately  no  real  medical  treatment.  The  pain 
and  distress  of  the  patient  may  be  alleviated  by  morphine,  but  a  recovery 
is  almost  unknown.  If  surgical  interference  is  undertaken,  it  should  be 
within  twelve  hours  of  the  occurrence  of  the  perforation,  if  it  is  to  have 
much  chance  of  success. 

Bed-sores  can  be  to  a  large  extent  prevented  by  a  careful  attention  to 
the  skin,  and  by  shifting  the  patient's  position,  or  by  a  water-cushion  or 
bed.  Where  the  surface  is  tender,  it  should  be  bathed  with  spirit  or  a  lead 
lotion.     When  a  sore  forms,  a  dressing  of  boric  or  zinc  ointment  is  useful. 

The  numerous  complications  and  sequelae  of  typhoid  fever  must  be 
treated  according  to  the  general  principles  applicable  to  their  nature. 

During  the  whole  of  convalescence,  and  even  for  a  long  time  after 
apparent  recovery,  care  should  be  exercised,  particularly  as  regards  diet, 
over-fatigue,  etc.  In  this  way  not  only  may  immediate  risks  be  prevented, 
but  a  condition  of  long-continued  weak  health  and  dyspepsia,  from  which 
many  typhoid  patients  subsequently  suffer,  may  be  obviated. 

Special  systems  of  treatment. — In  addition  to  the  general  principles 
of  treatment  given  above,  various  systems  have  been  tried  which  are  worthy 
of  notice. 

Treatment  directed  against  the  temperature. — Antipyretic  drugs  have 
been  very  popular,  and  are  still  very  generally  employed.  In  our  ex- 
perience, however,  they  are  undesirable.  The  ordinary  fever  of  a  typhoid 
case  runs  such  a  fixed  and  definite  course,  that  it  is  hard  to  believe 
that  the  pyrexia  is  not  nature's  cure  for  the  disease.  Apart  from  cases 
where  the  temperature  has  become  hyperpyretic,  we  have  seen  no  good 
resulting  from  the  use  of  antipyretics.  The  excuse  for  their  employment 
is  the  damaging  effect  of  a  continued  high  temperature  upon  the  cardiac 
muscle. 


TYPHOID  FEVER.  145 

If  any  drug  is  to  be  used,  quinine  is  probably  at  once  the  safest  and  the 
most  efficient,  and  in  cases  of  hyperpyrexia  it  may  be  extremely  useful. 
Its  dose  should  vary  from  15  to  25  grs.,  according  to  the  severity  of  the 
case.  Phenazone,  acetanilide,  and  the  whole  group  of  coal-tar  derivatives, 
should  be  avoided.  In  the  first  place,  they  occasionally  cause  cyanosis, 
with  dangerous  collapse ;  and  secondly,  what  is  more  important,  they 
prevent  to  a  large  extent  the  free  elimination  of  the  toxines  of  the  disease. 

Hydrotherapeutic  means  have  been  used  with  much  more  success. 
Of  these  Brand's  system  is  by  far  the  most  important ;  and  although  it 
has  never  had  a  fair  trial  in  this  country,  it  has  given  admirable  results  on 
the  Continent  and  in  America.  The  technique  of  the  system  consists  in 
immersing  the  patient  in  a  bath  whenever  the  temperature  taken  in  the 
rectum  reaches  102o-2  F.  The  bath  is  not  to  be  warmer  than  65°  F.  A 
compress,  dipped  in  water  of  about  5°  lower,  is  placed  on  the  head  of  the 
patient,  or  cold  water  may  be  placed  over  the  head  and  shoulders.  Com- 
presses of  ice-cold  water  are  placed  on  the  chest  and  the  abdomen.  The 
patient  remains  in  the  bath  fifteen  minutes,  during  which  he  is  encouraged 
to  rub  himself,  and  is  systematically  rubbed  down  by  his  attendants.  This 
friction  is  of  great  importance,  and  is  designed  to  stimulate  the  peripheral 
circulation.  About  eight  or  ten  minutes  after  immersion,  shivering  usually 
begins,  but  this  is  to  be  disregarded,  and  the  full  time  prescribed  should  be 
occupied  in  the  process.  The  patient  is  then  removed,  wrapped  in  a  coarse 
linen  sheet,  over  which  a  blanket  is  folded,  and  the  extremities  are 
thoroughly  dried  and  rubbed.  A  little  alcohol  is  then  usually  administered. 
The  bath  is  to  be  repeated  every  three  hours,  unless  the  temperature 
remains  below  102°'2  F.  The  diet  should  consist  of  liquids,  and  no  drugs 
are  given. 

In  spite  of  the  apparent  severity  of  this  treatment,  the  death  rate  of 
typhoid  fever  has  been  considerably  lowered  in  all  hospitals  where  it  has 
been  systematically  used.  The  great  secret  of  its  success  would  appear  to 
lie  in  the  fact,  not  that  it  lowers  temperature,  but  that  it  promotes  elimina- 
tion. Diuresis  is  much  more  free,  and  the  toxines  are  discharged  in  much 
greater  quantity.  Its  danger  appears  to  be  the  risk  of  causing  shock,  in 
case  of  weak  heart.  In  such  cases  it  is  better  to  start  with  a  bath  at  the 
temperature  of  the  room.  The  method  has  been  accused  of  increasing  the 
chances  of  haemorrhage,  but  as  the  dangerous  haemorrhage  of  typhoid  is 
always  ulcerative,  it  is  not  easy  to  see  how  it  could  be  affected  by  external 
conditions. 

Various  applications  of  cold  water  and  ice  will  be  found  very  useful  in 
high  degrees  of  fever.  Cold  sponging  and  cold  packing  are  perhaps  the 
easiest  methods  to  adopt,  and  usually  do  very  well.  Graduated  baths, 
where  the  water  is  cooled  down  from  the  temperature  of  the  patient,  are 
also  effectual  in  reducing  temperature,  and  have  the  advantage  of  avoiding 
shock. 

Another  systematic  water  treatment  is  that  of  Barr,  who  keeps  his 
patients  during  the  whole  course  of  their  fever  in  a  tank  bath,  kept  at  a 
few  degrees  below  the  temperature  of  the  patient. 

Treatment  directed  against  the  bacteria  and  their  products. — Drugs. — 
Various  attempts  have  been  made  to  cut  short  the  course  of  the  fever 
by  the  administration  of  antiseptic  drugs.  While  complete  success  has 
not  been  obtained,  many  observers  have  had  favourable  results.  It  is 
obviously  impossible  to  make  the  bowel  aseptic,  but  it  is  possible,  by 
the  administration  of  certain  drugs,  to  effectually  deodorise  the  stools.  Of 
vol.  1. — 10 


146  GENERAL  DISEASES. 

these  drugs  salol  is  perhaps  the  most  used,  and  may  be  given  in  doses  of 
10  grs.  every  four  or  six  hours.  We  have  had,  however,  better  results 
with  naphthol  (3,  in  doses  of  6  to  9  grs.  every  four  hours.  G-uaiacol  car- 
bonate also  gives  good  results.  Calomel  has  long  been  popular  in  typhoid 
fever,  and  is  very  useful  combined  with  any  of  the  above  remedies  through- 
out the  course  of  the  whole  fever.  Other  well-known  antiseptics  are 
salicylate  of  bismuth,  naphthalin,  turpentine,  eucalyptus  oil,  and  thymol. 
Chlorine  water  is  also  frequently  used. 

Of  these  antiseptics,  it  may  be  said  that  they  do  not  injure  the  patient, 
they  do  not  cut  short  the  fever,  and  they  do  not  prevent  relapses.  On  the 
other  hand,  they  deodorise  the  stools,  and  possibly  thus  reduce  the  risks 
run  by  the  attendants.  They  may  also  modify  the  ulceration,  and  lessen 
the  severity  of  the  attack. 

Antitoxine. — There  is  yet  no  true  antitoxine  for  typhoid  fever.  The 
serum  so  called  is  a  bactericidal  preparation,  but  does  not  probably  directly 
counteract  the  toxines  of  the  disease.  We  have  not  seen  much  advantage 
in  its  use.  What  will  always  prevent  a  very  successful  serum  treatment 
of  typhoid  fever  is,  that  it  is  so  pre-eminently  a  disease  which  c<  »mes  late 
under  medical  observation.  To  obtain  much  effect  with  any  antitoxine,  it 
is  necessary  to  get  the  cases  early. 

J.  0.  AFFLECK. 
CLAUDE  B.  KER. 


VAEIOLA  AND  VACCINIA. 


Syn.,  Fr.,  Petite  ve'role ;  G-er.,  Blattern  or  Pocken. 
Syn.,  Fr.,  Vaccine  ;  Ger.,  Kuhpocken. 

An  acute,  specific,  highly  infectious  febrile  disease,  setting  in  suddenly 
with  chills,  headache,  vomiting,  sweating,  salivation,  tenderness  on  pressure 
in  the  pit  of  the  stomach,  and  severe  pain  in  the  lumbar  and  sacral 
regions.  The  range  of  temperature  is  characteristic:  high  before  the 
rash  appears,  it  falls  with  the  coming  out  of  the  true  eruption,  to  rise 
again  as  a  secondary  fever  develops,  when  suppuration  takes  place  at 
the  end  of  the  first  week.  There  is  a  specific  inflammation  of  the  skin 
(dermatitis)  and  often  of  the  mucous  membranes  also.  The  dermatitis 
is  shown  by  the  development,  usually  on  the  third  day,  of  a  papular 
or  pimply  rash,  which  quickly  becomes  vesicular,  and  finally,  in  many 
cases,  pustular.  These  pustules,  in  the  end,  dry  up,  and  form  foul- 
smelling  and  extremely  infectious  crusts,  which  are  cast  off  or  shed  about 
the  eighteenth  day.  The  disease  is  not  infrequently  complicated  with 
haemorrhages  into  the  skin  {purpuric  smallpox),  and  from  the  mucous 
membranes  (Jicemorrhagic  smallpox) ;  these  may  occur  early,  and  interfere 
with  the  development  of  the  true  smallpox  eruption;  or  late,  constitut- 
ing Variola  hemorrhagica  pustulosa  (Curschmann).  In  convalescence  a 
remarkable  tendency  to  the  formation  of  boils  and  abscesses  is  observed  in 
the  severer  cases,  especially  in  those  accompanied  by  a  profuse  and  general 
rash  {confluent  smallpox). 

History. — The  origin  of  smallpox  is  unknown.  Its  native  foci  were 
most  likely  situated  in  China,  India,  and  Central  Africa.  Its  diffusion 
eastward  and  westward  was  probably  effected  by  the  Saracen  armies  at 
the  era  of  the  Hegira,  A.D.  622.     The  name  "variola"  occurs  for  the  first 


VARIOLA   AND    VACCINIA. 


i47 


time  as  a  designation  of  the  disease  in  a  description  by  Marius,  of  an 
epidemic  which  was  widely  prevalent  in  France,  Switzerland,  and  Italy, 
in  the  year  570.  The  researches  of  antiquarians  lead  to  the  belief  that 
smallpox  first  appeared  in  England  about  A.D.  900.  ■  All  authors 
concur  in  representing  the  frightful  mortality  occasioned  by  this  pestilence, 
and  the  consequent  terror  which  its  visitations  everywhere  excited. 
Holinshed,  in  the  sixteenth  century,  was  the  first  to  use  the  word 
"smallpox."  Writing  of  an  epidemic  which  occurred  in  the  reign  of 
Edward  in.,  he  says :  "  Alsoe  manie  died  of  the  smalljoocJces,  both  men, 
women,  and  children."  In  the  Middle  Ages,  the  death  toll  of  smallpox 
could  be  counted  by  millions.  Before  the  introduction  of  vaccination, 
just  a  century  ago,  the  annual  mortality  from  the  disease  in  England  and 
Wales  alone  was  at  the  rate  of  3000  in  every  million  of  the  population. 
In  1890  smallpox  caused  only  fifteen  deaths  in  England;  and  the  average 
annual  number  of  deaths  from  this  disease  in  the  ten  years  1881-90 
was  1,227"8 — that  is,  only  one-seventieth  part  of  the  death-rate  of  pre- 
vaccination  times.  Thus  great  has  been  the  boon  conferred  upon  mankind 
by  the  discovery  of  Jenner. 

Etiology. — To  Boerhaave  belongs  the  credit  of  assigning  contagion 

■cent  Jan.        Feb.         Mar.         Apr.       May         dune         duly       Aug.       Sept.         Oct.        Nou.         Dec. 


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2 

. 

30 

50   - 

i: 

Fig.  11.— Smallpox  mortality  curve. 

as  the  proper  exciting  cause  of  smallpox.  Outbreaks  of  the  disease 
occur  periodically,  over  wide  districts  or  in  localities  of  limited  area,  and 
independently  of  climate,  soil,  or  race,  whenever  the  contagium,  virus,  or 
essential  poison  of  smallpox  is  introduced  among  a  population  open  to  its 
reception;  that  is  to  say,  a  population  unprotected  by  a  previous  visitation, 
or  by  inoculation,  or  by  vaccination.  Although  smallpox  is  apparently 
independent  of  climate,  yet  the  season  of  the  year  has  a  marked  influence 
upon  its  prevalence.  It  is  essentially  a  disease  of  winter  and  spring.  In  the 
British  Islands  and  Western  Europe  generally,  for  example,  the  monthly 
number  of  cases  is  high  from  November  onward ;  but  from  May  a  rapid 
decline  in  the  prevalence  of  the  disease  takes  place,  the  least  number  of 
cases  being  observed  in  September.  The  critical  mean  temperature  in 
regard  to  smallpox  appears  to  be  50°  F.  When  the  mean  falls  below  that 
value,  the  disease  spreads ;  when  it  rises  above  it,  the  disease  wanes.  The 
explanation  is  no  doubt  to  be  found  in  the  fact  that  defective  ventilation, 
overcrowding,  and  deficient  nutrition,  wait  on  cold  weather,  and  these  are 
the  most  powerful  predisposing  causes  of  smallpox  no  less  than  of  typhus 
fever. 

The  curve,  Fig.  11,  based  on  the  returns  for  London  of  the  Eegistrar- 


148  GENERAL  DISEASES. 

General  for  England  during  the  fifty  years  1841-1890,  clearly  illustrates 
the  seasonal  prevalence  of  smallpox. 

Individual  susceptibility  to  the  poison  of  smallpox  extends  to  the  whole 
of  mankind,  but  experience  shows  that  the  coloured  races,  and  particularly 
the  negro  race,  are — other  things  being  equal — in  greater  risk  from  small- 
pox than  the  whites. 

Turning  from  the  predisponents  of  the  disease  to  its  causa  causans, 
or  exciting  cause,  we  are  led  by  analogy  to  regard  the  virus  as  microbic 
in  its  nature,  although  we  are  obliged  to  admit  that  the  bacteriology 
of  smallpox  is  still  incomplete.  Klein  has  described  a  peculiar  and 
extremely  minute  bacillus,  or  rod-shaped  micro-organism,  as  occurring  in 
the  calf  lymph  and  in  human  variola  lymph  during  the  early  phases — 
in  the  calf  lymph,  seventy-two  to  ninety-six  hours  after  vaccination ;  in 
the  human  variola,  during  the  third  or  fourth  day.  In  both  instances 
the  lymph  was  collected  aseptically.  In  the  bacilli — when  abundant — 
forms  were  recognised  in  which  some  globules  resembling  spores  existed. 
Calf  lymph  of  later  stages  (five  or  six  days  old)  showed  no  bacilli,  or 
only  here  and  there  a  trace.  The  presence  of  these  spore-like  bodies, 
and  the  absence  of  bacilli  in  the  lymph  of  later  stages,  led  Klein  to 
conclude  that  in  smallpox  and  the  vaccine  disease  we  have  to  deal  with 
a  spore-forming  bacillus.  The  bacilli  multiply  in  the  early  phases,  spores 
are  then  formed,  and  it  is  these  which  prevail  in  the  lymph  of  the  later 
phases.  This  would  explain  the  preservation  of  the  active  principle  of 
vaccine  lymph  in  glycerin,  which  is  a  germicide  for  cocci  and  sporeless 
bacilli,  but  not  for  spores.  It  would  equally  explain  the  continued  activity 
of  vaccine  lymph  dried  on  ivory  or  bone  points,  for  such  prolonged  drying 
would  kill  all  but  spores. 

Klein's  researches  have  apparently  been  confirmed,  and  his  views 
have  received  independent  support  through  investigations  carried  out  by 
Christian  Bay.  This  observer  has  obtained  from  vaccine  lymph  cultiva- 
tions in  beef  bouillon,  rendered  alkaline  with  sodium  chloride,  of  colourless, 
non-motile  bacilli,  with  a  long  diameter  measuring  from  '6  /i  to  1  p,  and 
the  short  diameter  from  "2  /a  to  '3  //,.  These  organisms  were  found,  with 
three  exceptions,  in  examinations  of  sixty-five  cultures  from  vaccine  points. 
These  bacilli  bear  spores  from  an  early  stage  of  their  development.  The 
organism  contains  two  spores,  one  at  each  end.  As  this  is  the  most  con- 
spicuous feature  of  the  organism,  Bay  refers  it  to  the  genus  Dispora,  and 
calls  it  D.  variolar.  The  same  organism  was  also  found  in  the  lymph  from 
a  case  of  confluent  smallpox  in  the  Smallpox  Hospital,  Chicago.  Of  forty 
cultures  in  bouillon  made  from  this  lymph,  only  two  failed  to  show  the 
presence  of  Bay's  bacillus. 

Smallpox  is  a  typically  infectious  disease.  Most  usually  it  spreads 
from  person  to  person.  It  clings  to  articles  of  furniture  or  of  dress,  which 
therefore  act  as  fomites,  or  carriers  of  the  infection.  It  may  be  conveyed 
through  the  medium  of  an  individual,  not  himself  ill  of  it,  as  in  a  striking 
case  reported  by  Hewitt.  It  may  be  acquired  from  the  dead  body. 
Watson  tells  that  the  corpse  of  a  man  who  had  died  of  smallpox  was 
brought  into  the  dissecting-room,  with  the  result  that  four  students  took 
the  disease.  As  Hirsch  graphically  puts  it,  "an  atmosphere  of  smallpox 
poison  develops  around  the  sick,  especially  when  they  are  crowded  in  close 
rooms."  In  other  words,  "  the  air  may  become  a  carrier  of  the  contagion, 
so  that  the  latter  can  be  spread  by  the  atmospheric  currents  within  a 
small  range."     Although  Hirsch  thought  that  no  mathematical  expression 


VARIOLA  AND    VACCINIA.  149 

could  be  found  for  the  extent  of  that  range,  and  that,  at  the  utmost,  it 
went  no  farther  than  the  immediate  surroundings  of  the  sick,  yet  the 
experience  of  recent  epidemics  in  the  British  Isles  proves  that  the  striking 
distance  of  smallpox  is  considerable — certainly  much  greater  than  that  of 
typhus  fever.  In  the  Sheffield  outbreak  of  1887-1888,  the  infecting 
influence  of  the  smallpox  hospital  could  be  distinctly  traced  along  a  radius 
of  4000  feet.  Wynter  Blyth  observes  that  this  possibility  of  smallpox 
spreading  by  aerial  infection  increases  greatly  both  the  hospital  difficulty 
and  that  of  individual  isolation.  There  can  be  no  doubt  that  the  chief 
stages  of  infectiveness  in  smallpox  are  the  earliest  period  of  suppuration, 
and  the  stage  of  desiccation,  crusting,  or  scabbing. 

Morbid  anatomy  and  pathology. — As  regards  the  skin,  Unna 
shows  that  the  poisoned  epithelium  in  the  upper  prickle  layer  of  the  rete 
mucosum  softens,  becomes  cedematous  from  swelling  of  the  protoplasm 
within  the  epithelial  cells,  while  a  secondary  coagulation  of  the  albuminoid 
bodies,  set  free  from  the  epithelial  protoplasm,  takes  place,  constituting  a 
fibrinoid  degeneration  of  the  epithelium.  In  smallpox,  this  advances  slowly 
— much  more  slowly  than  in  chickenpox — and  is  quickly  followed  by  sup- 
puration. This  arises  partly  from  intense  inflammation,  partly  from  a 
secondary  infection  of  the  skin  by  pyogenic  micro-organisms. 

Owing  to  the  slow  advance  of  the  colliquation,  or  softening  of  the 
prickle  cells,  other  epithelial  cells  are  compressed  into  trabecule,  or  septa, 
perpendicular  in  the  centre,  and  directed  somewhat  outwards  at  the  sides. 
The  younger  epithelial  cells  of  the  lower  prickle  layer  meanwhile  assume 
the  form  of  hollow  spheres  or  balloons.  Unna  accordingly  describes  the 
fibrinoid  degeneration  of  the  epithelium  in  smallpox  as  presenting  two 
forms — reticulating  and  ballooning  colliquation.  The  first  predominates 
at  the  periphery  of  the  pock ;  the  second  at  its  centre. 

Umbilication  is  to  be  ascribed,  in  the  vesicular  stage,  in  part  to  reticu- 
lating degeneration,  in  part  to  epithelial  oedema.  Of  these,  the  former  is 
often  especially  developed  at  the  periphery  of  the  pock;  the  latter  is 
always  limited  to  the  periphery.  The  less  swollen  centre,  where  ballooning 
colliquation  predominates,  simply  remains  behind.  Unna  admits  that, 
where  a  hair  follicle  accidentally  runs  through  the  centre  of  the  pock,  a 
form  of  depression  may  be  produced,  for  the  swelling  of  the  prickle  layer 
will  here  be  limited  by  the  cornified  neck  of  the  hair  follicle.  But  this 
exceptional  case  does  not  explain  the  characteristic  central  depression  of 
the  smallpox  vesicle.  This  depends  on  the  two  changes  in  the  periphery 
of  the  pock,  which  have  been  named  reticular  colliquation  and  cedematous 
swelling  of  the  epithelium,  while  ballooning  degeneration  or  colliquation 
leads  only  to  a  very  slight  increase  in  the  centre  of  the  vesicle.  Hence  the 
periphery  is  prominent ;  the  centre  is  depressed,  and  apparently  retracted. 

From  the  fifth  day  onward,  the  blood  vessels  throughout  the  cutis  are 
dilated.  A  full  stream  of  leucocytes  causes  an  ever-increasing  infarction 
or  plugging  of  the  vesicle  or  pustule,  which  is  thus  converted  into  an 
almost  solid  tissue ;  or,  if  the  horny  layer  of  the  cutis  yields,  a  more  or 
less  profuse  suppuration  lasts  for  a  time,  or  speedily  ends  in  the  formation 
of  a  crust  or  scab.  When  the  scab  is  thrown  off,  a  persistent,  trough-like 
depression  is  displayed.  The  depth  of  the  scar  depends  on  the  degree  and 
the  duration  of  the  flattening  of  the  base  of  the  pock  beneath  the  pustule 
and  the  scab.  Hence  Unna  says  that  "  the  rational  treatment  to  avoid 
scars  should  be  mainly  directed  to  the  aborting  of  the  pustular  stage,  and 
the  rapid  removal  of  the  scab  by  profuse  epithelial  new  growth." 


150  GENERAL  DISEASES. 

The  liver,  kidneys,  spleen,  and  heart  muscle  undergo  important  morbid 
changes.  The  spleen  swells;  its  pulp  becomes  soft,  and  of  a  light-red 
colour.  The  liver,  kidneys,  and  heart  muscle  are  the  seat  sometimes  of 
cloudy  swelling  (granular  degeneration),  sometimes  of  acute  fatty  degenera- 
tion, resembling  that  produced  by  poisoning  with  phosphorus.  In  malignant 
smallpox,  large  or  small  haemorrhages  may  be  found  in  nearly  all  the 
viscera,  ecchymoses  in  the  serous  membranes,  and  extravasations  of  blood 
in  almost  all  the  mucous  membranes. 

Symptomatology — Stages. — The  course  of  smallpox  may  be  divided 
into  five  stages — incubation,  invasion,  eruption,  secondary  fever,  desiccation, 
and  desquamation. 

Incubation. — This  begins  with  the  reception  of  the  virus  into  the 
system,  and  ends  when  the  earliest  symptoms  appear.  Its  average  duration 
is  twelve  days  inclusive,  except  after  inoculation,  when  it  is  only  eight  days 
or  less.  A  familiar  example  of  the  process  is  the  everyday  practice  of 
vaccination,  or  the  engrafting  of  the  vaccine  disease  by  puncture  of  the 
skin,  and  the  insertion  into  the  wound  of  vaccine  lymph.  As  a  rule, 
there  are  no  symptoms  in  this  stage,  which  is  therefore  called  the 
latent  period.  Towards  its  close,  however,  the  patient  feels  unwell  and 
out  of  sorts. 

Invasion. — Smallpox  sets  in  suddenly  and  with  violence.  The  earliest 
symptoms  are  connected  with  the  nervous  system.  They  are :  chills, 
rigors,  and — in  young  children — convulsions ;  lumbar  or  sacral  pain,  from 
hyperemia  of  the  spinal  cord ;  pain  in  the  pit  of  the  stomach,  nausea, 
and  often  vomiting,  severe  headache,  delirium,  rheumatoid  pains  in  the 
limbs.  There  is  constipation,  except  in  children,  in  whom  diarrhoea, 
sleepiness  or  drowsiness,  and  stupor  may  occur.  Constant  profuse  sweating 
is  usual.  There  are,  besides,  loss  of  appetite,  thirst,  furred  tongue,  very 
foetid  breath,  full  and  rapid  pulse,  and  prostration.  In  women,  menstruation 
nearly  always  comes  on,  whether  the  period  is  due  or  not,  and  it  is  generally 
profuse.  All  these  symptoms  are  apt  to  be  more  acute  and  persistent  in 
confluent  than  in  discrete  smallpox. 

On  the  first  or  second  day  the  temperature  rises  quickly  to  104°  F. 
(=40°  C),  seldom  below  this  point,  sometimes  above  it — even  to  105o-8  F. 
(=  41°  C).  The  maximal  temperature  is  usually  reached  shortly  before  the 
rash  appears  on  the  third  day.  This  initial  fever  is  called  the  prodromal 
fever,  because  it  thus  runs  before  or  precedes  the  appearance  of  the 
eruption. 

During  this  stage  accidental  rashes  are  apt  to  appear,  causing  much 
difficulty  in  diagnosis.  They  are  usually  erythematous  in  character — if 
diffuse,  resembling  scarlatina  or  erysipelas ;  if  spotty,  or  macular,  resem- 
bling measles.  This  prodromal  or  initial  erythema  is  called  roseola  vario- 
losa. It  is  very  evanescent,  and  may  usher  in  an  attack  of  varioloid  or 
modified  smallpox ;  and  so  it  has  no  little  prognostic  value.  It  probably 
depends  'on  a  reactive  inhibition  of  the  vasomotor  system  of  nerves, 
brought  about  by  the  fever  poison.  Parts  of  the  body  affected  by  a 
roseola  variolosa  may  afterwards  remain  free  from  the  true  smallpox  rash. 
A  more  serious  sign  is  the  development,  even  at  this  early  stage,  of  petechias, 
or  extravasations  of  dissolved  hsematin  under  the  skin,  varying  in  size  from 
a  pin's  head  to  a  pea  or  a  bean.  These  purpuric  rashes  are  commonly  seen 
on  the  sides  of  the  chest  or  over  the  lower  part  of  the  abdomen  and  the 
inner  aspect  of  the  thighs — the  brachial  and  crural  triangles.  The  stage 
of  invasion  lasts  on  the  average  for  three  days ;  as  a  rule,  it  is  prolonged 


VARIOLA  AND    VACCINIA.  151 

in  the  milder,  shortened  in  the  severer  cases,  so  far  as  the  amount  of  the 
true  rash  is  concerned.  This  rule  may  be  accepted  as  a  sound  working 
proposition,  although  there  is  one  striking  exception  to  it.  In  consequence 
of  great  organic  lesions,  the  eruption  may  be  retarded  till  the  sixth  or  seventh 
day  in  both  discrete  and  confluent  cases.  A  purpuric  or  hemorrhagic 
tendency  early  in  smallpox  postpones,  it  may  be  indefinitely,  the  showing 
of  the  true  rash 

Eruption. — The  true  rash  of  smallpox  appears  first  on  the  head,  face, 
and  neck,  and  about  the  wrists,  next  on  the  trunk,  and  lastly  on  the  lower 
extremities.  The  usual  time  for  its  appearance  is  the  third  day  inclusive 
from  the  earliest  symptoms.  In  confluent  cases  it  may  show  itself  on  the 
second  or  even  on  the  first  day ;  in  discrete  cases  its  coming  may  be  post- 
poned until  the  fourth  day. 

The  "  pocks  "  appear  on  the  first  day  of  the  rash  as  points  of  hyperemia, 
like  the  fine  pricks  made  with  a  needle,  or  like  recent  fiea-bites.  Owing 
to  changes  in  the  rete  mucosum  and  to  cell  proliferation,  a  papule  or 
pinrple  quickly  forms.  This  is  slightly  raised,  conical,  and  hard,  feeling 
like  a  grain  of  shot  beneath  the  skin — it  feels  shotty  on  the  second  and 
third  days  of  the  rash.  Exudation  of  serum  soon  takes  place,  so  that  the 
horny  layer  of  the  epidermis  is  raised  to  form  a  vesicle.  Its  contents, 
clear  at  first,  soon  become  opaque,  lactescent  or  milk-like,  on  the  fourth 
and  fifth  days  of  the  rash.  Pustules  or  small  abscesses  are  then  formed 
through  further  changes  in  the  vesicles,  in  which  young  cells  increase 
and  multiply,  their  contents  becoming  yellow  and  purulent  on  the  sixth 
and  seventh  days  of  the  rash.  About  this  time  also  a  central  depression 
or  dimple  is  found  in  these  pustules,  owing  to  epithelial  oedema  at  the 
periphery  of  the  pock.  This  is  the  so-called  umbilicus,  at  the  bottom 
of  which  the  opening  of  a  hair  follicle  or  sweat  gland  is,  according  to 
Curschmann,  frequently  seen.  The  variolous  inflammation  is  not  confined 
to  the  epidermis.  The  papillary  layer  of  the  derma  is  often  involved,  its 
connective  tissue  elements  proliferate  and  afterwards  undergo  cicatricial 
contraction,  leading  to  the  permanent  deformity  known  as  "  pitting."  A 
person  is  then  said  to  be  "pock-marked." 

The  period  of  fullest  development  of  the  rash  is  reached  on  the  seventh 
day  from  its  appearance — the  tenth  day,  inclusive,  of  the  disease.  Each 
pustule  is  now  surrounded  with  an  inflammatory  zone  or  areola,  called  its 
halo.  This  period  is  called  the  period  of  maturation  or  ripening.  It  lasts 
about  three  days,  and  is  followed  by  the  last  stage  in  the  life-history  of  the 
eruption,  that  of  desiccation — the  rupture  and  drying  up  of  the  pustules,  and 
the  formation  of  foul-smelling  crusts  or  scabs. 

Desiccation. — A  yellowish  matter,  like  thick  honey,  oozes  from  the 
surface  of  the  pustules.  This,  with  the  pus  or  serum,  speedily  dries  up, 
first  in  the  centre ;  and  brownish  scabs  form,  which  are  at  first  adherent, 
but  afterwards  fall  off  in  from  three  to  six  days,  leaving  elevations  or 
projections  of  a  violet-red  hue,  like  a  cold  skin.  With  the  drying  up  of  the 
pustules,  the  redness,  swelling,  and  tenderness  of  the  skin  subside,  the  eyes 
reopen,  the  nostrils  are  cleared,  and  the  features  of  the  patient  become  once 
more  recognisable. 

Desquamation. — After  the  eighteenth  day,  or  so,  of  the  attack  in  con- 
fluent cases,  successive  scales  of  epidermis  form  and  peel  off — a  process 
which  is  called  desquamation,  or  scaling — ultimately  leaving  a  small  white 
puckered  scar,  or  "pit,"  should  the  variolous  inflammation  of  the  skin 
have  dipped  deep  and  involved  the  papillary  portion,  or  cutis  vera.     When 


152  GENERAL  DISEASES. 

every  scab  has  fallen  off,  and  desquamation  has  ceased,  the  patient  may  be 
considered  free  from  infection. 

The  rash  of  smallpox  is  by  no  means  confined  to  the  skin.  A  true 
variolous  exanthem  or  endanthem  develops  upon  the  mucous  membranes 
in  general.  The  conjunctivae,  the  mucous  membranes  of  the  nose,  mouth, 
pharynx,  and  adjacent  parts,  are  nearly  always  affected.  The  rash  may 
thence  extend  through  the  whole  system  of  mucous  membranes,  invading 
the  larynx,  trachea,  and  bronchi  in  one  direction ;  the  oesophagus,  stomach, 
and  intestines  in  another.  Thence  arise  many  of  the  more  serious  com- 
plications of  smallpox.  The  eyes  and  eyelids  are  inflamed,  and  sight  may 
be  lost.  We  may  have  deafness,  due  to  blocking  of  the  oedematous 
Eustachian  tubes ;  hoarseness  or  aphonia ;  cough  and  dyspnoea,  from  bronch- 
itis and  pneumonia ;  dysphagia,  or  difficulty  of  swallowing ;  diarrhoea ; 
colitis.  According  to  Curschmann,  true  pocks  upon  the  serous  membranes 
are  fables  belonging  to  antiquity. 

Varieties. — A  classification  of  smallpox,  based  upon  the  distribution 
and  amount  of  the  rash,  has  been  handed  down  from  the  time  of  Sydenham, 
and  has  received  universal  acceptance. 

Whether  modified  or  unmodified  by  a  previous  attack  or  by  vaccination, 
smallpox  appears  under  two  principal  forms — discrete  and  confluent.  The 
first  of  these  is  generally  free  from  danger ;  the  latter  is  one  of  the  most 
terrible,  loathsome,  and  fatal  of  diseases.  Of  confluent  smallpox,  two 
modified  varieties  are  described,  namely,  semiconfluent  or  coherent  small- 
pox, and  corymbose  smallpox. 

Variola,  discreta  vel  distincta  is  the  name  given  to  those  cases  in  which 
the  rash  is  sparse  or  scanty,  the  several  papules  or  pustules  being  more  or 
less  widely  separated  from  each  other ;  hence  the  term  discrete.  In  this 
form  the  initial  symptoms  are,  as  a  rule,  less  acute  and  less  per- 
sistent, and  the  rash  not  infrequently  stops  short  of  the  pustular  stage 
(  V.  crystallina). 

Variola  confiuens  is  the  term  applied  to  those  cases  in  which  the  rash 
overruns  the  entire,  or  nearly  the  entire,  surface  of  the  body,  and  invades  the 
mucous  membranes  also  with  great  severity.  The  invasion  symptoms  are 
all  intensified,  and  the  rash  appears  as  early  as  the  second  day.  In  this 
dangerous  variety  the  following  characteristic  symptoms  are  often  present: 
— Persistent  diarrhoea ;  profuse  salivation,  either  from  parotitis,  or  as  a 
reflex  symptom  from  stomatitis  (inflammation  of  the  mucous  membranes  of 
the  mouth);  great  swelling  of  the  face  and  eyelids,  so  that  the  latter 
sometimes  burst  or  slough ;  most  painful  swelling  of  the  hands  and  feet ; 
delirium — sometimes  busy  with  extreme  muscular  agitation,  often  violent, 
noisy,  homicidal,  or  suicidal.  In  this  variety  of  the  disease,  the  pocks  are 
pale,  crude,  pitted,  and  sessile.  The  face  is  covered  with  pustules,  which 
run  together,  so  that  the  epidermis  is  raised  by  a  milky  purulent  secretion, 
and  the  face  seems  as  if  it  were  dipped  in  tallow  or  covered  with  a  parch- 
ment mask. 

While  the  face  and  hands  may  be  absolutely  covered  with  pocks,  the 
eruption  may  be  more  or  less  discrete  in  other  parts  of  the  body,  the  amount 
and  intensity  of  the  pustulation  seemingly  bearing  a  direct  relation  to  the 
vascularity  and  inflammatory  state  of  the  surface.  The  mucous  membranes, 
like  the  skin,  are  the  seat  of  a  closely-set  rash  in  confluent  smallpox,  and 
very  dangerous  forms  of  secondary  inflammation  are  apt  to  place  the 
patient's  life  in  imminent  peril.  Towards  the  close,  should  the  patient 
survive,  multiple  pyaemic  abscesses,  erysipelas,  and  even  gangrene,  may 


VARIOLA  AND    VACCINIA. 


*53 


occur  in  those  parts  of  the  integument  where  the  confluence  is  most 
pronounced. 

The  mortality  is  of  course  very  great  in  this  form  of  the  disease,  at  any 
stage  of  which  the  patient  may  succumb.  Confluent  smallpox  is  the  most 
deadly  of  all  pestilences,  yellow  fever  and  cholera  not  excepted.  The  most 
fatal  epoch  is  about  the  eleventh  or  twelfth  day,  but  even  far  on  in  the 
stage  of  desiccation  death  not  seldom  results  from  exhaustion,  or  pyaemia, 
or  some  other  complication. 

Should  confluent  smallpox  end  in  recovery,  convalescence  is  very  tedious, 
and  is  often  interrupted  by  serious  sequela?,  of  which  an  "  acute  f uruncular 
diathesis,"  as  Trousseau  called  it,  is  one  of  the  commonest  and  most  trouble- 
some. It  shows  itself  in  the  formation  of  successive  crops  of  most  painful 
boils  and  carbuncles,  and  of  more  or  less  deep-seated  abscesses.  In  the 
stage  of  desiccation,  also,  large,  foul,  ecthymoid  crusts  may  form  upon  the 
ulcerated  surface  of  the  skin.  With  the  separation  of  the  scabs,  or  some- 
times later,  the  hair  commonly  falls  off,  at  times  in  handfuls.  The  resulting 
alopecia,  or  baldness,  is  occasionally  permanent. 


Day  of 
Disease 

3 

4 

5 

6 

7 

8 

9 

10 

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Fig.  12. — Discrete  smallpox. 


Fig.  13. — Discrete  smallpox. 


Variola  semiconfiuens,  or  coherent  smallpox,  is  where  the  pustules  touch 
each  other  without  coalescing,  or  the  eruption  is  confluent  on  and  about 
the  face,  and  more  or  less  discrete  elsewhere. 

Variola  corymbosa  is  a  term  applied  to  those  cases  where  the  pustules 
are  confluent  in  patches  or  clusters,  these  being  separated  by  intervals  of 
unaffected  skin.  Vascular  parts,  like  the  armpits,  groins,  and  popliteal 
spaces,  are  often  the  seat  01  such  a  rash.  According  to  Marson,  this  is 
a  very  fatal  variety  of  smallpox,  the  mortality  reaching  41  per  cent. 
Strangely  enough,  it  was  scarcely  less  destructive  to  vaccinated  persons 
than  to  those  who  were  unprotected. 

Temperature. — The  symptomatology  of  smallpox  would  not  be  complete 
without  at  least  a  brief  account  of  the  behaviour  of  the  body  temperature 
in  the  disease.  The  accompanying  charts  (Figs.  12-16)  have  been  selected 
to  illustrate  the  varying  grades  of  intensity  of  the  fever  movements  in 
smallpox.  Two  distinct  fever  types  are  observed.  The  prodromal  or 
initial  fever  of  the  stage  of  invasion  is  a  brief  continued  fever,  which  is 


*54 


GENERAL  DISEASES. 


often  very  severe,  even  in  the  mildest  cases  of  variola  discreta,  and  of 
varioloid  or  modified  smallpox.  In  these  forms  the  prodromal  fever  both 
begins,  and  commonly  completes,  the  febrile  movement.      Its  maximal 


Day  0/     4       5       6       7       8       9      10      II       12     13      14      15      16      17      18      19     20     21      22    23     24    25 

Disease 

105° 

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98° 

Fig.  14. — Coherent  smallpox — secondary  fever. 

temperature  is  rarely  less  than  104°  F.  (40°  C),  and  often  exceeds  this 
reading,  reaching  even  106°  F.  (41°-1  C.)  as  early  as  the  second  day.  Soon 
after  the  true  rash  appears,  the  temperature  falls  more  or  less  quickly — 
usually  from  the  fourth  to  the  sixth  day.     In  cases   of   uncomplicated 


Day  of 
Disease 

4 

5 

6 

7 

8 

9 

10 

n 

12      13 

14      15 

IG 

17 

18 

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19 

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Fig.  15. — Confluent  smallpox — severe  secondary  fever. 

varioloid,  and  of  mild,  discrete  smallpox,  this  defervescence,  or  cooling 
down,  is  complete  and  final. 

The  fall  of  temperature  which  occurs  with  the  coming  out  of  the  rash 
of  smallpox  is  pathognomonic  of  this  disease.  It  is  exactly  the  converse  of 
the  behaviour  of  the  temperature  in  measles,  in  which  the  fever  is  moderate 


VARIOLA  AND    VACCINIA. 


J55 


up  to  the  appearance  of  the  rash,  and  then  becomes  more  and  more  intense, 
until  the  rash  is  most  fully  developed. 

The  other  type  of  fever  in  smallpox  is  relapsing  in  character.  It  occurs 
in  the  severer  and  confluent  forms,  in  which  the  defervescence  of  the  erup- 
tive stage  is  incomplete.  In  other  words,  the  initial  fever  runs  on,  until, 
with  the  beginning  of  pustulation,  or  maturation  of  the  rash,  the  tem- 
perature again  begins  to  rise,  ushering  in  a  secondary  fever — the  fever 
of  suppuration,  or  of  maturation.  This  secondary  febrile  movement  is  of 
indefinite  duration,  and  varies  in  intensity  in  proportion  to  the  severity  of 
the  attack.  There  are  morning  remissions,  and  evening  exacerbations  of 
temperature,  with  occasional  spikings,  or  isolated  extreme  elevations. 
Eeadings  above  104°  F.  during  this  fever  of  suppuration  are  a  sign  of 
danger,  and,  in  fatal  cases,  hyperpyrexial  temperatures  (107o-6  F.  =  42°  C.) 
are  wont  to  occur  before,  at  the  moment  of, 
or  even  after,  death.  In  cases  which  tend 
towards  recovery,  defervescence  takes  place 
by  an  irregular  lysis,  or  gradual  resolution 
of  the  fever,  as  opposed  to  crisis,  in  which 
temperature  falls  briskly  and  permanently 

Apart  from  discrete  and  confluent  small- 
pox, we  meet  with  the  following  varieties: — 

Variola  benigna,  or  varioloid — a  mild  and 
abortive  form,  in  which  the  pocks  either  fail 
to  appear  at  all,  or  else  fail  to  pass  through 
the  later  stages  of  their  development,  stopping 
short  at  the  papular  stage ;  or,  if  reaching  the 
vesicular  stage,  drying  up  and  shrivelling  on 
the  fifth  or  sixth  day  of  the  eruption. 

Variola  maligna —  V.pur'purica  vel  hosmor- 
rhagica. — Apart  from  confluent  smallpox,  in 
which  the  patient's  life  is  endangered  by  the 
amount  of  suppuration,  and  the  intensity  of 
the  secondary  or  suppurative  fever,  malignant  smallpox  presents  itself 
under  two  forms — purpuric,  and  hemorrhagic.  These  forms  differ  merely 
in  degree ;  in  both  the  blood  is  profoundly  altered,  and  the  characteristic 
rash  of  smallpox  fails  to  appear  at  all,  or  to  run  through  its  several  stages. 

In  the  purpuric  variety  the  dissolution  of  the  blood  leads  to  the  forma- 
tion of  petechige,  vibices,  or  purple  streaks  and  blotches,  and  ecchymoses. 
Klebs  and  Unna,  however,  attribute  these  changes  to  blocking  of  the  vessels 
of  the  skin  by  bacteria. 

In  hsemorrhagic  smallpox,  heematolysis  is  carried  still  further.  The  ill- 
fated  patient  bleeds  from  every  pore  and  orifice  of  the  body.  The^e  is 
chemosis — he  may  even  weep  tears  of  blood.  There  is  epistaxis — he  bleeds 
from  lips  and  gums.  He  spits,  or  coughs  up,  or  vomits  blood.  The  motions 
from  the  bowels  are  tarry.  Blood  pours  from  the  kidneys,  and,  in  the 
female,  from  the  generative  organs.  The  tongue  looks  as  if  it  were  par- 
boiled, and  there  is.  an  unquenchable  thirst. 

One  of  the  most  extraordinary,  as  well  as  the  most  painful,  features  of 
this  deadly  malady  is  the  clearness  of  mind  which  often  remains  with  the 
unhappy  patient  almost  up  to  the  time  when  he  draws  his  latest  breath. 
There  is,  in  some  of  these  cases,  no  delirium,  no  stupor,  no  dulling  of  the 
intellect  whatever;  the  victim  literally  looks  death  in  the  face  in  full 
possession  of  his  senses. 


Day  of 
Disease 

8 

4 

5 

6 

7 

8 

9 

10 

105° 
104° 

103° 

102° 

101° 

100° 

99° 

Normal 
98° 

T 

\ 

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A 

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si 

/ 

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Fig.  16. — Malignant  smallpox. 


156  GENERAL  DISEASES. 

Strong,  muscular  men,  and  pregnant,  or  recently-delivered  women,  are 
said  to  be  particularly  liable  to  fatal  haemorrhagic  smallpox.  Hemorrhagic 
or  purpuric  symptoms  occasionally  supervene  during  the  eruptive  stage. 
The  true  exanthem  may  indeed  become  the  seat  of  haemorrhage  in  its 
papular,  vesicular,  or  pustular  stage,  first  and  especially  on  the  lower 
extremities.  This  is  the  V.  hemorrhagica  pustulosa  of  Curschmann,  long 
ago  described  by  Sydenham  as  Anomalous,  Irregular,  or  Black  Smallpox 
(  V.  nigra). 

Sequelae. — The  complications  and  sequelae  of  smallpox  are  many  and 
often  severe.  Multiple  abscesses  and  boils  may  involve  the  skin,  constitut- 
ing the  "  f uruncular  diathesis  "  of  Trousseau.  The  eyelids  may  suppurate 
or  slough ;  atrophic  keratitis,  iritis,  panophthalmitis,  or  retinal  haemorrhage 
may  endanger  or  destroy  sight.  (Edema  of  the  glottis,  ushered  in  by 
aphonia,  often  causes  death  about  the  eighth  day.  Laryngitis  may  lead 
to  ulceration  of  the  cartilages.  Bronchitis,  pneumonia,  or  pleuritis,  with 
purulent  effusion  from  the  outset,  may  occur ;  and  the  nervous  system  may 
suffer  severely,  various  paralyses  or  disseminated  sclerosis  being  occasion- 
ally observed.  Acute  mania  sometimes  follows.  Pyaemia,  or  septicaemia 
and  joint  disease,  with  painful  swellings,  effusions  of  serum  or  pus,  inflam- 
mations of  cartilages  and  of  bones,  may  occur. 

Diagnosis. — The  prodromal  fever  of  smallpox  may  be  mistaken  for 
simple  continued  fever,  which  has  no  rash,  or  for  scarlatina  because  of  the 
vomiting,  but  the  marked  sore  throat  of  the  latter  disease  is  wanting. 

The  early  stage  of  the  smallpox  rash  closely  resembles  that  of  measles, 
but  coryza  is  absent  or  slight.  In  measles,  also,  fever  increases  as  the  rash 
develops,  whereas  in  smallpox  it  subsides.  The  "  Grisolle  sign "  is  a 
certain  means  of  diagnosis.  If,  upon  stretching  an  affected  portion  of 
the  skin,  the  papule  ceases  to  be  felt,  the  rash  is  that  of  measles ;  if,  on 
the  contrary,  the  papule  is  still  felt,  hard  and  shotty,  the  rash  is  that  of 
smallpox.  Measles  attacks  children ;  smallpox,  as  a  rule,  adults.  The  pain 
in  the  back  is  wanting  in  measles. 

The  onset  of  smallpox  often  closely  resembles  that  of  typhus  ;  but  the 
fever  persists,  and  the  rash  is  macular  rather  than  papular  in  the  latter 
disease.  The  clinical  history  should  solve  the  question  of  a  pustular 
syphilide  or  smallpox,  of  glanders  or  smallpox,  and  of  erysipelas  or  smallpox. 
The  differential  diagnosis  of  variola  and  varicella  (chiekenpox)  had  best  be 
postponed  until  the  latter  disease  has  been  described. 

Prognosis. — The  mortality  depends  on — the  patient's  state  as  regards 
previous  protection  by  an  attack  of  natural  smallpox,  by  inoculation,  or  by 
vaccination ;  the  virulence  of  the  disease  itself — the  haemorrhagic  form 
being  the  ■  most  deadly,  next  the  purpuric  form,  then  the  confluent  form ; 
the  general  hygienic  condition,  or  otherwise,  of  the  patient's  surroundings ; 
the  presence  or  absence  of  complications  or  sequelae. 

Smallpox  is  most  deadly  to  unvaccinated  children  under  5  years  of  age, 
and  to  unvaccinated  adults  over  30  years.  Of  the  confluent  cases,  50  per 
cent,  perish  ;  of  the  most  malignant  cases,  100  per  cent.  The  influence  of 
vaccination  for  good  is  unquestionable — the  mortality  being  50  per  cent, 
among  the  unvaccinated  in  general,  26  per  cent,  among  the  badly 
vaccinated,  and  only  2-3  per  cent,  among  the  efficiently  vaccinated. 

Haemorrhagic  or  malignant  smallpox  may  kill  in  four,  five,  or  six  days 
from  the  onset.  In  confluent  smallpox,  on  the  contrary,  the  patient 
seldom  dies  before  the  eleventh  clay — the  most  fatal  epochs  being  the 
twelfth,  thirteenth,  and  fourteenth  days. 


VARIOLA  AND    VACCINIA.  157 

Defective  sanitary  surroundings — such  as  overcrowding,  want  of  venti- 
lation, bad  house  drainage — enormously  increase  the  patient's  risk. 

The  complications  and  sequelae  often  kill  a  patient  who  may  have 
escaped  the  perils  which  beset  him  in  the  earlier  stages  of  the  attack. 
(Edema  of  the  glottis,  inflammation  of  the  cartilages  of  the  larynx, 
bronchitis,  pleurisy,  or  diarrhoea,  may  kill  straight  off;  while  pyaemia, 
septicaemia,  and  the  furuncular  diathesis  may  exhaust  the  patient's  strength 
after  weeks  or  months  of  suffering. 

Treatment. — This  naturally  falls  under  two  headings  —  preventive 
and  curative  treatment. 

Prophylaxis. — The  principles  of  the  preventive  treatment  of  smallpox 
are  based  upon  two  facts  in  the  natural  history  of  the  disease — it  is 
eminently  communicable,  one  attack  usually  protects  an  individual  from 
a  second  attack — in  other  words,  it  confers  immunity  upon  him.  The 
preventive  measures  which  call  for  remark  are — isolation  of  the  sick, 
inoculation,  vaccination. 

Isolation  consists  in  the  removal  of  the  sick  to  suitable  epidemic 
hospitals,  the  providing  of  refuges  for  the  inmates  of  infected  tenement 
houses  or  other  dwellings,  efficient  disinfection,  and  the  establishment  of 
convalescent  homes. 

As  regards  Inoculation,  the  intention  was  to  engraft  a  mild  form  of 
smallpox  on  a  healthy  individual,  whose  receptivity  or  susceptibility  might 
be  supposed  to  be  slight  or  low  in  consequence  of  his  existing  good  health. 
The  disadvantages  of  this  procedure  were  that  it  gave  smallpox  to  many 
who  would  otherwise  have  perhaps  escaped  the  disease  altogether,  while 
it  was  not  possible  to  guarantee  that  the  resulting  attack  of  smallpox  would 
be  mild.     Inoculation  is  now  illegal  in  Great  Britain  and  Ireland. 

Vaccination. — About  the  middle  of  the  eighteenth  century,  the  opinion 
gained  ground  in  England  that  inoculation  with  cowpox  lymph  protected 
from  smallpox.  It  is  necessary  to  explain  that  various  domestic  animals 
are  liable  to  a  disease  which  is  practically  smallpox.  Cowpox  is  an  instance. 
In  this  affection  the  eruption  is  almost  exclusively  observed  upon  the  udder 
and  teats  of  the  cow.  The  malady  is  technically  called  Variolas  vaccina,  or 
shortly  Vaccina  (less  correctly  Vaccinia).  Dairymaids  and  farm-labourers 
were  liable  to  sores  upon  their  hands,  which  seemed  to  arise  from  contact 
with  pustules  on  the  udders  of  milch  cows.  Those  who  suffered  from  this 
apparently  local  malady  of  sore  hands  were  observed  to  escape  smallpox. 
In  1771,  a  schoolmaster  in  Holstein,  named  Platte,  is  reported  to  have 
practised  vaccination.  In  1774,  Benjamin  Jesty,  a  Gloucestershire  farmer, 
inoculated  his  wife  and  two  sons  with  cowpox,  thus  performing  vaccination 
for  the  first  time  in  this  country.  On  May  14,  1796,  Edward  Jenner 
"  vaccinated  "  a  peasant  lad,  whom  he  failed  to  inoculate  with  smallpox  two 
months  afterwards.     Such  was  the  beginning  of  vaccination. 

Vaccinia. — The  symptoms  of  Cowpox,  or  the  Vaccine  Disease,  are  first 
local,  then  constitutional.  At  the  site  of  inoculation  with  vaccine  lymph, 
which  may  be  bovine  or  humanised — that  is,  derived  from  the  calf  or  heifer, 
or  from  a  human  being  already  vaccinated — a  patch  of  redness  appears  on 
the  third  day  inclusive.  This  rapidly  develops  into  a  papule  or  pimple,  which 
in  its  turn,  about  the  fifth  day,  becomes  surmounted  with  a  pearly  vesicle, 
multilocular,  oval,  or  circular  in  outline,  with  raised  margin  and  depressed 
centre.  This  vesicle  enlarges  until  the  eighth  day,  its  contents  increasing 
but  remaining  clear  as  crystal.  An  inflammatory  red  zone,  called  the 
areola,  now  develops,  spreading   out  from  the  base   of   the  vesicle  to  a 


158  GENERAL  DISEASES. 

distance  of  perhaps  two  or  three  inches.  After  the  tenth  day  the  areola 
fades,  the  vesicle  shrinks  and  dries  up  in  the  centre,  while  the  contained 
lymph  becomes  opaque,  and  thickens.  By  the  fourteenth  or  fifteenth  day  a 
hard,  dry  brown  scab  forms,  which  finally  separates  and  falls  off  about 
the  twenty-first  day.  A  circular,  slightly  depressed,  foveate  or  pitted  scar 
remains,  which  is  generally  permanent  through  after-life. 

The  constitutional  symptoms  are — slight  feverishness  from  the  fourth 
day,  becoming  more  marked  from  the  eighth  to  the  tenth  day ;  often  de- 
rangement of  the  stomach  and  bowels  during  the  stage  of  areola,  with 
restlessness.  The  axillary  glands  may  swell  and  rashes  may  show  upon 
the  skin — either  a  blush,  or  a  crop  of  papules,  or  a  vesicular  rash.  These 
symptoms  subside  in  a  few  days,  or  fail  to  appear  at  all. 

Vaccination  in  rare  instances  has  done  harm.  Unsuitable  subjects 
have  been  vaccinated,  or  impure  lymph  has  been  used.  The  syphilitic  j 
virus  has  been  inoculated  along  with  vaccine  lymph,  giving  rise  to  vaccino- 
syphilis,  the  most  deplorable  accident  by  which  carelessness  or  misfortune 
can  prejudice  the  performance  of  vaccination.  Such  mishaps,  however, 
afford  no  valid  argument  against  the  practice  of  vaccination. 

The  circumstances  which  conduce  to  the  success  of  the  operation  are 
these — 

The  subject  to  be  vaccinated  should  be  healthy,  neither  teething  nor 
being  weaned. 

The  vaccinifer  should  also  be  healthy,  vaccinated  for  the  first  time,  and 
above  all  free  from  any  syphilitic  taint. 

The  lymph  should  be  taken  not  later  than  the  eighth  day. 

The  incisions,  punctures,  or  scarifications  should  not  penetrate  to 
the  subcutaneous  areolar  tissue.  They  should  be  made  with  a  scrupu- 
lously clean  or  sterilised  instrument,  the  skin  having  been  first  washed  and 
sterilised  as  far  as  possible. 

Bleeding  should  be  avoided,  lest  the  lymph  be  washed  away  from  the 
site  of  inoculation. 

Lymph  which  has  been  drawn  from  a  vesicle  already  showing  the 
areola  should  not  be  used.     This  is  Jenner's  "  golden  rule." 

Thin,  serous,  readily  flowing  lymph  should  not  be  used.  Good  lymph 
is  perfectly  limpid  and  viscid  or  sticky. 

Curative  treatment. — No  specific  for  smallpox  has  yet  been  dis- 
covered. The  two  great  principles  of  treatment  are — to  guide  the  essential 
disorder  to  a  favourable  termination,  and  to  combat  secondary  affections  as 
they  arise. 

Discrete  smallpox. — The  patient,  having  been  placed  in  bed  in  a 
large,  airy,  and  well-ventilated  but  warm  room,  should  be  carefully  and 
skilfully  nursed.  His  hair  and  beard  should  be  cut  close,  his  face  and 
hands  should  be  washed  daily,  or  twice  a  day,  with  warm  carbolised 
water,  from  1  to  2  per  cent,  in  strength,  or  with  creolin  and  water,  or 
with  a  weak  solution  of  corrosive  sublimate  (mercuric  chloride,  1—2000). 
"Warm  baths  are  very  useful  and  refreshing.  The  water  may  with 
advantage  be' tinged  with  permanganate  of  potassium  solution,  unless  soap 
is  used.  Lindholm  employed  with  complete  success  the  method  recom- 
mended by  Finsen,  of  treating  smallpox  patients  in  a  room  from  which  the 
ultra-violet  rays  of  the  solar  spectrum  are  shut  out  by  red  window  panes,  or 
by  covering  the  windows  with  red  curtains.  The  eruption  dried  up  shortly 
after  its  appearance,  no  fever  of  maturation  took  place,  and  the  patients 
recovered  quickly,  having  but  few  scars,  even  when  at  first  severely  attacked. 


VARIOLA   AND    VACCINIA.  159 

Confluent  smallpox. — The  pain  in  the  back  is  relieved  by  dry- 
cupping,  by  applying  an  indiarubber  bag  filled  with  hot  water,  or  by  a 
hypodermic  injection  of  ergotin.  To  check  the  development  of  a  copious 
eruption,  the  red-light  treatment  may  be  adopted.  In  quinine  and  in 
perchloride  of  iron  we  possess  the  two  most  valuable  antiseptics  for 
internal  use.  Three  important  indications  for  treatment,  so  far  as  the 
rash  is  concerned,  are — the  exclusion  of  air ;  the  keeping  of  the  skin 
in  a  permanently  moist  state,  so  as  to  prevent  the  hardening  of  the 
scabs ;  the  lessening  of  the  local  irritation.  Many  suggestions  have 
been  made  to  fulfil  these  indications.  My  own  plan  is  to  apply  over  the 
face  a  light  mask  of  lint,  thoroughly  soaked  in  a  mixture  of  iced  water  and 
glycerin  (a  teaspoonful  in  an  ounce  of  water),  and  covered  with  oiled  silk. 
Similar  dressings  may  be  applied  to  the  hands  and  feet. 

Closely  akin  to  this  plan  and  like  measures,  is  the  treatment  by  the 
warm  or  tepid  bath.  Hebra  appears  to  have  had  his  attention  drawn 
to  this  method  of  treatment  through  observing  its  efficacy  in  the  man- 
agement of  extensive  burns.  Stokes  strongly  recommended  the  continuous 
warm  bath  as  a  palliative  in  the  delirium  and  pain  of  confluent  smallpox. 
He  held  also  that  marking  or  pitting  seldom  occurred  when  the  surface 
was  protected  from  the  air  from  an  early  period,  and  kept  in  a  permanently 
moist  condition.  The  continuous  warm  bath  fulfilled  the  three  important 
indications  of  treatment  above  mentioned,  and  that,  too,  as  regards  the 
entire  person  of  the  patient. 

The  treatment  of  such  skin  affections  as  bedsores,  abscesses,  boils, 
erysipelas,  and  gangrene,  consists  largely  in  scrupulous  cleanliness  and 
efficient  nursing.  The  body  linen  should  be  frequently  changed.  The 
patient  should  rest  on  a  water-bed,  or  a  woven  wire  mattress.  If  the  feet 
and  hands  are  wrapped  in  wet  cloths,  covered  with  oiled  silk  or  gutta- 
percha tissue,  the  intense  pain  which  attends  the  formation  of  pustules 
upon  the  soles  of  the  feet  and  palms  of  the  hands  will  be  avoided. 

The  eyelids  should  be  poulticed,  or  kept  covered  with  cold  compresses, 
to  reduce  cedema.  Lint  moistened  with  glycerised  water  (one  teaspoon- 
ful of  glycerin,  or  of  glycerin  of  carbolic  acid,  to  a  saucerful  of  tepid 
water)  is  an  excellent  application.  For  atrophic  keratitis,  cod-liver  oil, 
iron,  wine,  and  good  food  are  indicated. 

Affections  of  the  mouth,  tongue,  and  pharynx  are  best  treated  with 
ice  and  antiseptic  sprays  or  gargles.  In  cases  of  laryngitis,  ice  is  invaluable 
internally.  It  may  also  be  applied  to  the  neck  externally.  Hot  poulticing 
also  often  gives  relief,  or  fomenting  the  neck  with  sponges  wrung  out  of  hot 
water.  The  steam-kettle  should  be  kept  going,  and  the  patient  should  be 
placed  in  a  croup  tent,  and  plied  with  food  and  stimulants  at  short  but 
regular  intervals. 

Diarrhoea  is  often  controlled  by  a  starchy  diet,  with  milk  sterilised  by 
boiling,  by  exhibiting  brandy  or  port  wine,  and  by  poulticing  the  abdomen. 
Salicylate  of  bismuth,  salol,  or  carbonate  of  guaiacol  will  be  found  useful. 
Solution  of  pernitrate  of  iron  may  be  prescribed,  or  pills  of  acetate  of  lead 
and  opium,  or,  in  the  case  of  children,  aromatic  chalk  powders.  Ten 
drops  of  glycerin  of  carbolic  acid  and  ten  drops  of  tincture  of  chloroform 
and  morphine  are  an  excellent  combination,  given  at  intervals  as  required. 
For  children  the  dose  should  be  lessened  according  to  age. 

While  it  too  often  happens  that  all  our  efforts  to  combat  hemorrhagic 
smallpox  are  in  vain,  yet  we  may  save  life  by  the  administration  of  the 
solution  or  tincture  of  ferric  chloride  in  full  doses — 30  minims  every  third 


160  GENERAL  DISEASES. 

hour,  or  of  gallic  or  tannic  acid  in  5-  to  10-gr.  doses,  or  of  turpentine  and 
ergot,  or  of  liquid  extract  or  tincture  of  hamamelis  in  full  doses.  In 
monorrhagia  and  metrorrhagia,  also,  cold  applied  to  the  vulva  is  of  use,  or 
slapping  the  buttocks  with  cloths  dipped  in  ice-cold  water.  Hot  water 
may  be  injected  into  the  vagina  with  advantage. 

In  these  awful  cases  stimulants  are  imperatively  called  for — brandy, 
whisky,  or  wine,  according  to  circumstances,  and  especially  egg-flip  and 
turpentine  punch.  Inhalation  of  oxygen  should  be  tried,  and  perhaps 
transfusion  of  blood,  as  recommended  by  Curschmann. 

J.   W.   MOORE. 


VABICELLA— CHICKENPOX. 

Syn.,  G-er.,  die  Wasserpocken,  die  Jliegende  Blatter  ;  Fr.,  Petite  ve'role 
volante  ;  Old  Eng.,  Waterpox  or  Glasspox ;  Scot.,  Crystalpox. 

An  acute,  specific,  very  infectious  febrile  disease,  especially  of  infancy  and 
early  childhood,  not  dangerous  to  life,  characterised  by  the  appearance 
on  the  skin  of  successive  crops  of  clear,  colourless,  watery  vesicles.  It  is 
a  separate  and  distinct  disease  from  smallpox.  The  accompanying  fever 
is  usually  moderate  and  remittent  in  type,  increasing  and  abating  as  the 
vesicular  rash  comes  and  goes. 

History. — About  1550,  two  medical  writers,  Vidus  Yidius  and 
Ingrassias  of  Naples,  described  the  disease  under  the  name  Crystalli,  owing 
to  the  clear,  crystalline  contents  of  the  vesicles.  The  malady  was  first 
fully  described  in  England  by  Heberden  in  1766,  under  the  name  of 
Variolce  pusillm.  Two  years  previously,  Vogel  is  said  to  have  introduced 
the  term  "  Varicella,"  which,  like  "  Variola,"  is  a  diminutive  of  the  Latin 
varus,  a  pimple.  Heberden  pointed  out  that  it  was  important  to  recognise 
chickenpox,  because  those  who  had  it  might  otherwise  be  deceived  into  a 
false  security,  which  might  prevent  them  from  keeping  out  of  the  way  of 
the  smallpox  or  from  being  inoculated. 

Etiology. — Chickenpox  is  essentially  a  disease  of  childhood,  and 
usually  occurs  before  the  first  dentition  is  completed.  Even  sucklings  may 
be  attacked,  but  among  children  over  10  years  of  age  the  disease  is 
infrequent.  Nevertheless,  many  instances  are  on  record  of  adults  con- 
tracting the  disease.  In  1889  a  friend  of  mine,  set.  25  years,  himself  a 
member  of  the  medical  profession,  had  in  Dublin  a  well-marked  attack ; 
and  in  1894  a  gentleman,  set.  32,  passed  through  a  typical  attack  under  my 
observation. 

Chickenpox  shows  itself  sporadically,  or  in  moderate  and  often-repeated 
local  epidemics  quite  independently  of  smallpox.  Its  appearance  is  not 
determined  by  season,  but  it  often  follows  in  the  wake  of  other  specific 
fevers — notably  scarlatina. 

The  intimate  nature  of  the  specific  virus  of  varicella  is  as  yet  unknown. 
It  is  supposed  that  the  virus  is  generally  inhaled.  Only  rarely  can  it  be 
inoculated.  Its  tenacity  of  life  does  not  seem  to  be  great.  In  marked 
contrast  with  the  practical  non-inoculability  of  chickenpox,  is  the  facility 
of  its  dissemination  among  little  children  by  contagion.  As  a  rule  one 
attack  confers  a  lifelong  immunity  on  an  individual 

Morbid  anatomy  and  pathology.  —  According  to  Unna    the 


VARICELLA — CHICKENPOX  161 

varicellous  process  commences  with  the  reticulating  liquefaction  of  a  few 
prickle  cells  of  the  central  and  upper  prickle  layer,  in  the  middle  of  the 
first-appearing  congestive  spot.  The  completely  liquefied,  confluent  cavities 
rapidly  dilate  to  form  the  vesicles;  the  persistent  non-liquefied  epithelium  is 
compressed  to  form  the  septa,  as  are  the  cells  above  to  form  the  cover  of 
the  conoidal,  or  tent-shaped,  vesicle.  Its  contents,  at  the  height  of  its 
development,  consist  of  finely  granular,  coagulated  fibrin,  enclosing  a  few 
fibrinously  degenerating,  compressed,  or  ballooned  epithelial  cells,  and 
scarcely  any  wandering  cells. 

The  acuteness  which  distinguishes  the  varicellous  process  is  evident 
histologically  (in  distinction  to  smallpox)  in  the  relatively  large,  slightly 
septate  cavities,  due  to  the  rapid  distension  of  a  few  liquefied  cells.  Not- 
withstanding its  appearance,  the  chickenpock  is  certainly  not  monolocular. 
Its  thin  covering  and  superficial  position  result  from  rapid  formation. 

The  non-purulent  character  of  chickenpox  is  histologically  very  pro- 
nounced. "  Its  benign,  unscarred  course,"  Unna  says,  "  is  explained  by  the 
superficial  position,  the  absence  of  purulent  infection  of  the  vesicle,  and 
the  early  repair  by  young  epithelium,  indicated  by  the  numerous  mitoses 
around  the  cavity.  The  absence  of  a  dimple  results  from  the  acute, 
abortive  course  of  chickenpox,  which  does  not  permit  the  formation  of  a 
swollen  peripheral  zone  of  reticularly  degenerated  and  very  cedematous 
epithelium." 

Symptomatology. — The  stage  of  incubation  or  latency  is  thought 
to  be  on  the  average  about  as  long  as  that  of  smallpox,  namely,  twelve 
days.  Towards  the  close  of  this  stage  there  is,  according  to  Thomas,  in 
some  cases  a  slight  rise  of  temperature. 

The  state  of  invasion  is  badly  marked.  The  child  often  feels  perfectly 
well  until  the  rash  appears  or  is  accidentally  discovered.  In  other  cases, 
malaise,  loss  of  appetite,  a  feeling  of  sickness,  headache,  chilliness,  and 
muscular  pains,  precede  the  rash  by  a  few  hours,  or  one  to  even  three  days. 
The  prodromal  fever  is  usually  slight — sometimes  a  sudden  rise  of  tempera- 
ture to  101°,  or  even  to  104°,  takes  place  just  before  the  rash  comes  out. 

The  stage  of  eruption  may  be  ushered  in  by  a  roseolar,  scarlatiniform 
rash,  but  the  true  rash  consists  of  papules  or  macules,  like  the  rose  spots 
of  typhoid  fever,  fading  on  pressure,  and  rapidly  developing  into  vesicles, 
containing  a  clear,  watery,  but  afterwards  straw-coloured  lymph.  These 
vesicles  do  not  become  pustular,  as  a  rule,  and  are  not  attended  by  an 
inflammatory  areola.  They  appear  first  on  the  trunk,  especially  the  chest, 
then  on  the  face  and  scalp,  and  finally  on  the  limbs.  They  increase  in  size 
up  to  the  third  or  fourth  day,  when  they  are  as  large  as  split  peas.  They 
become  acuminated  or  conoidal,  and  finally  burst,  shrivel,  and  dry  up. 
When  air  obtains  access  to  the  vesicles,  the  term  windpox  (  Varicella  ventosa, 
emphysematosa)  is  applied  to  the  case.  The  visible  mucous  membranes,  as 
well  as  the  skin,  are  the  seat  of  an  eruption  of  flat  vesicles,  with  lactescent 
contents.     Umbilication  is  inconstant,  often  absent. 

The  febrile  movement  is  not  acute.  It  is  remittent,  increasing  at  night 
and  in  proportion  to  the  amount  of  the  rash,  which  may  continue  to  come 
out  in  successive  crops  for  as  many  as  ten  or  twelve  days.  In  very  mild 
cases,  fever  may  be  entirely  absent.  Defervescence,  when  it  occurs,  takes 
place  quickly. 

The  stage  or  process  of  desiccation  varies  in  duration  like  that  of  eruption. 
Individual  vesicles  dry  up  quickly,  their  contents  being  in  part  absorbed, 
in  part  extravasated  through  bursting  of  their  walls.     A  small  brown  crust 

VOL.   I. II 


1 62  GENERAL  DISEASES. 

forms.  When  it  falls  off,  "  there  remains  only  rarely  a  slightly  depressed, 
smooth,  soft,  non-pigmented  scar,"  which  finally  leaves  no  trace.  A  per- 
manent pit,  or  scar,  may  remain  when  a  vesicle  has  become  a  pustule. 
Varicella  bullosa  is  due  to  a  secondary  infection  with  pyogenic  micro- 
organisms. Unless  in  rare  cases,  there  is  no  secondary  fever,  and  chicken- 
pox,  if  uncomplicated,  seldom  or  never  destroys  life.  So-called  relapses  are 
probably  examples  of  recurrent  crops  of  the  rash. 

Complications  and  sequelse  may  almost  be  said  not  to  exist.  Jonathan 
Hutchinson,  however,  drew  attention  to  a  formidable,  though  happily  rare, 
variety  of  the  disease,  to  which  he  gave  the  name  of  Varicella  gangrenosa. 
This  dangerous  form  was  described  by  Whitley  Stokes,  under  the  name  of 
Pemphigus  gangramosus,  and  was  well  known  in  Ireland  in  past  times  as 
"  White  Blisters,"  the  "  Eating  Hive,"  and  the  "  Burnt  Holes."  Radcliffe 
Crocker  points  out  that  this  gangrenous  eruption  may  occur  in  parts  not 
the  seat  of  the  varicellous  rash,  and  it  is  well  known  and  is  described  as 
Dermatitis  gangrenosa  by  many  writers.  Varicella  of  the  larynx  is  danger- 
ous, and  may  destroy  life. 

Diagnosis. — Chickenpox  may  be  confounded  with  lichen,  herpes, 
pemphigus,  and  varioloid.  From  the  three  first-named  skin  affections  it  is 
sufficiently  distinguished  by  the  age  of  the  patients,  their  previous  history, 
and  the  course  of  the  disease.  It  is  of  the  first  importance  to  correctly 
diagnose  varicella  from  smallpox.  In  cases  of  doubt  it  will  be  better  for 
the  physician  to  act  as  if  the  disease  were  really  varioloid,  in  order  to 
protect  the  community.  At  the  same  time,  that  varicella  is  a  disease  of 
its  own  kind  absolutely  distinct  from  smallpox,  admits  of  no  doubt. 

Differential  Diagnosis. — The  grounds  upon  which  a  differential 
diagnosis  is  based  are — 

Chickenpox  may  prevail  in  an  epidemic  form  without  smallpox.  On 
the  other  hand,  varioloid  has  never  been  prevalent  without  coincident 
smallpox. 

Young  children  are  attacked  by  chickenpox,  adults  by  smallpox,  in  a 
population  protected  by  vaccination. 

Varioloid  was  rare  in  prevaccination  times,  when  chickenpox  was  as 
prevalent  as  it  is  now. 

Vaccinated  children  readily  take  chickenpox — not  so  smallpox. 

Children  who  have  had  chickenpox  may,  conversely,  contract  smallpox, 
even  soon  afterwards. 

The  two  diseases  may  co-exist. 

The  virus  of  chickenpox  never  gives  rise  to  smallpox,  and  the  converse 
is  believed  to  be  equally  true. 

Smallpox  is  notoriously  inoculable — not  so  chickenpox. 

Smallpox  rarely  attacks  the  same  person  twice.  Second  attacks  of 
chickenpox  are  not  so  uncommon. 

The  rash  of  chickenpox  may  set  in  after  twenty-four  hours — that  of 
varioloid  is  postponed  to  the  fourth  or  fifth  day. 

The  febrile  movement  in  chickenpox  continues  after  the  spots  appear, 
— that  in  varioloid  subsides. 

In  chickenpox,  the  spots  come  out  in  successive  crops,  and  the  fever  is 
slight  and  remittent. 

The  characters  of  the  spots  are  different  in  the  two  diseases. 

Chickenpox  is  not  a  fatal  malady,  whereas  even  a  mild  form  of  smallpox 
may  cause  death. 

Prognosis  and  treatment. — The  simplest  measures  suffice  in  the 


MORBILLI— MEASLES — RUBEOLA.  163 

management  of  a  disease  which  is  generally  so  harmless.  All  that  is 
necessary  is  to  keep  the  child  indoors,  prescribe  a  milk  and  broth  diet, 
avoid  strong  animal  foods,  and  regulate  the  bowels  by  gentle  aperients. 
If  the  skin  is  dry  and  itchy,  it  is  most  desirable  to  protect  the  vesicles 
from  injury  by  rubbing  or  scratching,  lest  a  secondary  and  more  severe 
dermatitis,  resulting  in  scarring,  should  be  set  up.  In  varicella  of  the 
larynx,  either  intubation  or  tracheotomy  may  be  required. 

J.  W.  MOORE. 


MORBILLI— MEASLES— RUBEOLA. 
Syn.,  Fr.,  Bougeole;  Ger.,  Maseru. 

A  highly  infectious,  acute,  febrile  disorder,  usually  setting  in  with,  and 
throughout  accompanied  by,  catarrh  of  the  mucous  membranes,  especially 
those  of  the  eyes,  nose,  and  respiratory  passages;  characterised  by  the 
appearance  on  the  fourth  day  of  a  deep  rose-red,  or  crimson  inclining  to 
purple,  eruption  of  soft  papules  or  pimples,  which  spreads  over  the  whole 
body  in  the  course  of  thirty-six  hours,  and  is  preceded  and  accompanied 
by  sharp  fever.  This  terminates  by  crisis  between  the  sixth  and  eighth 
days,  coincidently  with  the  fading  of  the  rash.  Convalescence  is  apt  to  be 
complicated  with  affections  of  the  glandular  system  and  respiratory  organs. 

History. — The  native  seat  of  measles  is  unknown.  The  disease  was 
probably  widely  diffused  over  Europe  and  Asia  in  the  Middle  Ages.  Its 
distribution  at  the  present  day  is  practically  coextensive  with  the  habit- 
able globe.  Its  separate  identity  was  first  shadowed  forth  by  Forestus 
(1563),  but  it  is  to  Sydenham  (1676)  that  we  owe  the  full  differential 
diagnosis  between  measles  and  smallpox. 

Etiology. — Measles  is  a  disease  of  all  ages,  although  children  under  6 
months  enjoy  comparative  immunity,  being  less  susceptible  to  the  infection. 
In  communities  unprotected  by  a  previous  outbreak,  measles  attacks 
individuals  of  all  ages.  Striking  illustrations  of  this  statement  are  to  be 
found  in  the  history  of  outbreaks  in  the  Faroe  Islands  (1846),  the  Fiji 
Islands  (1875),  and  the  Samoan  group  (1893).  In  all  these  instances  age 
afforded  no  protection — old  men  and  women  falling  victims  as  readily  as 
young  children,  because  they  were  not  protected — had  not  been  rendered 
immune — by  a  previous  attack.  Under  these  circumstances  measles  is  a 
deadly  disease. 

The  bacteriology  of  measles  is  as  yet  undetermined.  In  1892,  Canon  and 
Pielicke  described  bacilli,  which  they  found  in  the  blood,  expectoration,  and 
nasal  and  conjunctival  mucus  of  patients  suffering  from  measles,  and  which 
they  believe  to  be  specific.  In  any  event,  the  materies  morbi  may  be  held 
to  exist  in  the  expectoration,  the  mucous  discharges,  and  the  cutaneous 
dSbris.  Measles  is  infectious,  from  the  first  sneeze  or  cough.  Hence 
the  difficulty  of  controlling  its  spread.  It  is  most  infectious,  however,  in 
the  eruptive  stage,  and  probably  not  very  infectious  in  desquamation.  Its 
"  striking  distance  "  is  believed  to  be  considerable,  but  the  contagium  is  less 
persistent  than  that  of  scarlatina.  One  attack  usually,  but  not  necessarily, 
protects  from  a  second — acquired  immunity  is  not  so  constant  after  measles 
as  it  is  after  smallpox.  The  disease  may  attack  the  fcetus  in  ulero. 
Measles  prevails  chiefly  in  the  spring  and  autumn.     A  mean  temperature 


164 


GENERAL  DISEASES. 


above  58°*6  and  one  below  42°  are  equally  inimical  to  its  prevalence. 
These  facts  are  well  illustrated  in  Fig.  17,  which  shows  the  seasonal 
prevalence  of  measles  in  London  during  fifty  years,  1841-1890,  as  proved 
by  the  returns  of  the  registrar -general  for  England. 

Morbid  anatomy  and  pathology. — A  specific  catarrhal  in- 
flammation of  the  mucous  membranes  of  the  respiratory  and  of  the 
intestinal  tracts  is  first  among  the  pathological  changes  in  measles.  The 
nasal  mucus,  according  to  Mayr  and  Hebra,  is  at  first  transparent,  after- 
wards opaque  ;  its  reaction  is  always  alkaline. 

G-.  Simon  ascribes  the  measles  papule  to  oedema  of  the  cutis,  not  to 
exudation  in  the  hair  follicles  and  sebaceous  glands.  In  this  view  Unna 
coincides.  He  holds  that  the  appearances  point  to  the  fact  that  spastic 
resistance  in  the  cutaneous  vessels  is  added  to  the  primary  congestive 
hyperemia,  which  develops  around  the  infection  in  the  capillaries.  (Edema 
of  the  cutis  and  the  hypoderm  exists,  whereas  there  is  an  almost  complete 
absence  of  a  cellular  exudation.  In  1891,  Catrin  examined  a  case  of 
rougeole    boutonneuse,   or   "nodular   measles,"   and   found   in   the   papule 


percen 
SO 

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Feb. 

Mar. 

Apr 

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June 

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Sept. 

Oct. 

Nov 

Dec. 

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Fig.  17. — Measles  mortality  curve. 

marked  diapedesis  of  white  corpuscles,  especially  along  the  blood  vessels, 
follicles,  and  coil  glands.  He  further  described,  as  characteristic  of  the 
nodular  form  of  the  eruption,  a  series  of  deep  epithelial  changes,  consisting 
of  colloid  transformation  and  coagulation  necrosis  of  the  epithelium. 
Unna  thinks  that  we  should  regard  these  changes  as  a  direct  result  of  the 
specific  poison,  which  has  somehow  exceptionally  reached  the  epithelium, 
as  it  does  in  smallpox.  The  scaling  of  the  epidermis  in  these  severe  cases 
is  naturally  more  profound  and  persistent. 

Symptomatology. — Stages. — A  typical  case  of  measles  runs 
through  four  stages — incubation,  invasion,  eruption,  and  desquamation. 

Incubation. — Ten  days  as  a  rule  elapse  between  the  reception  of  the 
poison  into  the  system  and  the  development  of  the  earliest  febrile  and 
catarrhal  symptoms.  This  stage  is  shortened  to  eight  days  after  inocula- 
tion. Few  or  no  symptoms  attend  this  preliminary  period.  Towards  its 
close,  fatigue,  lassitude,  and  nausea  may  be  felt,  and  there  is  sometimes  an 
ephemeral  or  passing  fever,  followed  by  defervescence. 

Invasion. — The  initial  or  prodromal  stage  is  longer  in  measles  than  in 
any  other  of  the  exanthemata.  It  lasts  four  or  five  days.  The  attack 
begins  suddenly  with  the  ordinary  nervous  symptoms  of  an  acute  fever, 
and  in  addition  a   remarkable  group  of  symptoms  connected  with  the 


MORBILLI— MEASLES — R  UBE  OLA  1 6  5 

mucous  membranes — sneezing,  itching,  and  swelling  of  the  eyelids,  which 
are  intensely  red  on  the  inside ;  watering  of  the  eyes,  which  look  bloodshot 
and  shun  the  light.  The  nose  feels  stuffed  and  often  bleeds ;  the  patient 
has  a  "bad  cold  in  the  head."  The  throat  is  raw  and  sore,  the  voice 
becomes  husky,  and  a  hoarse,  brassy  cough  sets  in,  occurring  in  paroxysms. 
In  many  cases  there  is  a  catarrhal  diarrhoea,  the  motions  being  green  and 
unhealthy  in  appearance  and  odour.  On  the  second  day  an  accidental 
erythematous  rash  may  show  itself,  simulating  scarlatina.  The  skin  is  hot 
and  dry,  and  the  thermometer  rises  to  102° -5  or  even  104°  F.  by  the  even- 
ing of  the  first  day.  This  initial  fever  gives  way  quickly,  so  that  on  the 
morning  of  the  third  day  the  temperature  is  normal  (980,4  F.),  or  only 
slightly  febrile  (99°  or  100°  F.)  As  the  true  rash  appears,  the  temperature 
again  rises  briskly.  Even  on  the  second  day  an  eruption  of  scattered 
points  and  spots  may  be  seen  on  the  soft  palate  and  buccal  mucous 
membrane.  Koplik  has  recently  drawn  special  attention  to  these  spots. 
Drowsiness  and  sleepiness  are  constant  symptoms  in  the  pre-eruptive  stage. 

Eruption. — Towards  the  close  of  the  fourth  day,  the  true  rash  is 
heralded  by  a  renewed  rise  of  temperature  and  an  exacerbation  of  all  the 
symptoms  connected  with  the  mucous  membranes.  The  eruption  shows 
on  the  face  first,  next  on  the  back  of  the  wrists,  afterwards  on  the 
trunk,  lastly  on  the  limbs.  It  consists  of  small  red  specks,  slightly 
elevated  and  velvety  to  the  touch,  on  the  forehead  and  face  closely 
resembling  flea-bites.  These  specks  become  grouped  in  crescentic  patches, 
leaving  interstices  of  skin  of  normal  colour.  The  rash,  therefore,  is  in 
general  discrete  rather  than  confluent.  It  is  of  a  deep  rose  or  crimson 
hue,  inclining  to  purple.  The  face  swells  somewhat.  Miliary  vesicles 
with  an  inflamed  red  base  may  appear  in  crops.  The  rash  sometimes  turns 
livid  or  black.  The  perspiration  has  a  peculiar  heavy  odour,  compared  by 
Memeyer  to  the  smell  of  a  freshly  plucked  goose. 

The  rash  develops  fully  in  thirty-six  hours.  It  is  then  dusky,  while 
the  skin  looks  rough  and  dirty — it  is  beginning  to  peel  or  desquamate. 
As  the  rash  comes  out  the  coryzal  and  catarrhal  symptoms  increase,  and 
so  does  the  fever  to  104°  or  105°  F. — being  most  intense  when  the  eruption 
is  at  its  height  on  the  evening  of  the  fifth  day,  or  on  the  sixth  day. 

With  the  fading  of  the  rash  defervescence  begins,  and  is  almost  com- 
pleted within  forty-eight  hours,  being  so  rapid  and  sudden  as  to  be 
diagnostic.  As  the  rash  fades  it  leaves  yellowish  red  stains,  which  may 
persist  for  several  days,  resembling  the  measly  rash  of  typhus  fever.  The 
morbillous  catarrh — both  respiratory  and  intestinal — frequently  persists  at 
this  stage,  and  a  nummular  sputum  shows  that  the  bronchioles  share  in 
the  affection. 

Desquamation. — This  commonly  begins  about  the  eighth  and  ends  about 
the  eighteenth  day.  The  skin  peels  off  in  fine,  branny  scales,  hence  the 
term  furfuraceous  desquamation.  This  may  escape  notice,  but  a  careful 
search  will  reveal  it  across  the  bridge  and  along  the  sides  of  the  nose,  as 
well  as  about  the  mouth  and  on  the  neck. 

In  uncomplicated  measles  convalescence  is  complete  in  eighteen  days 
from  the  earliest  symptoms.  In  rare  cases  a  relapse  of  the  true  rash  has 
been  known  to  occur,  together  with  a  return  of  the  fever  movement. 
These  relapses  are  of  short  duration. 

According  to  Thomas,  measles  in  which  there  is  rash  but  no  catarrh 
is  especially  apt  to  occur  in  very  young  infants,  and  is  attended  with 
little  or  no  fever.    Probably  many  cases  of  Eotheln  (rubella)  were  formerly 


i66 


GENERAL  DISEASES. 


classified  as  non-catarrhal  measles.  The  occurrence  of  measles  without  the 
rash  is  probably  a  rare  clinical  experience. 

Of  malignant  measles,  three  varieties  are  named — Purpuric  measles  i 
asthenic  or  adynamic  measles  ;  and  complicated  measles. 

The  purpuric  variety  is  very  infrequent.  It  is  observed  chiefly  in  young 
and  sickly  children.  The  rash  is  profuse  and  dark,  the  skin  is  dotted  over 
with  petechise  and  vibices,  while  blood  oozes  from  the  several  mucous 
membranes.  In  the  asthenic  or  adynamic  form  the  symptoms  are  severe  and 
persistent — the  fever  runs  high,  causing  early  exhaustion,  the  pulse  becomes 
rapid  and  weak,  delirium  gives  place  to  somnolence,  and  the  patient  sinks 
into  the  typhoid  or  ataxic  state.  This  term  is  applied  to  a  group  of 
symptoms  which  indicate  extreme  nervous  prostration,  namely,  sleepless- 
ness, low  muttering  delirium,  small  rapid  pulse,  quick  shallow  breathing, 
agitation  and  restlessness,  tremors,  plucking  at  the  bedclothes,  dilatation 


Day  of 
Disease 

7 

8 

9 

10 

ii 

12 

106° 
105° 

104° 

103° 

102° 

101° 

100° 

99° 

Normal 
98° 

97° 

Day  of 
Disease 

2 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

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103° 

102° 
101° 
100° 

99° 

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98° 

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Fig.  18. — Ordinary  Measles. 


Fig.  19. — Defervescence  in  Measles. 


of  the  pupils,  and  in  the  end  deepening  coma,  or  unconsciousness  and 
insensibility. 

Complications. — The  chief  complications  of  measles  are — convulsions 
in  young  or  nervous  children,  spasmodic  catarrhal  laryngitis,  suffocative 
catarrh,  diarrhoea,  colitis,  with  glairy,  bloody,  offensive  stools,  and 
tenesmus ;  epistaxis  or  nose-bleeding,  otitis,  diphtheria  of  the  pharynx 
and  larynx  (membranous  laryngitis  or  true  croup),  capillary  bronchitis  and 
catarrhal  pneumonia,  pleuritis,  and,  in  the  stage  of  desquamation,  glandular 
enlargements  in  the  neck  and  thorax,  cancrum  oris  or  noma,  gangrene 
of  the  vulva,  acute  miliary  tuberculosis,  and  chronic  ophthalmia,  with 
granular  lids. 

Suffocative  catarrh  may  occur  in  any  stage  of  measles.  Its  symptoms 
are — high  fever,  oppression  of  the  chest,  dyspnoea,  and  moist  cough.  In 
young  children  this  disseminated  broncho-pneumonia  (for  such  ib  is)  is 
dangerous  from  purely  mechanical  causes — suffocation  is  brought  about  by 
oedema  of  the  bronchial  mucous  membrane,  paralysis  of  the  muscular  fibres 


MORBILLI— MEASLES— R  UBE  OLA.  1 6  7 

of  the  bronchioles,  and  resulting  accumulation  of  secretion.  An  attack 
of  measles,  besides  giving  rise  to  complications  and  sequeke  such  as 
have  just  been  named,  often  sows  the  seed  of  even  a  fatal  constitutional 
delicacy. 

Temperature. — The  fever  movements  in  measles  are  highly  character- 
istic. In  the  stage  of  incubation,  a  short  preliminary  fever  in  the  form 
of  an  ephemera  may  occur — the  thermometer  possibly  rising  to  102°*8  or 
103°-6  F.  An  initial  or  prodromal  fever  constantly  occurs  in  the  stage  of 
invasion,  temperature  rising  to  102o-4  or  even  101°  F.,  on  the  evening  of 
the  first  day.  A  fall  succeeds,  temperature  being  either  normal  or  sub- 
febrile  on  the  third  day.  The  true  eruptive  fever  begins  shortly  before 
the  rash  is  due,  develops  with  the  out-coming  of  the  rash,  and  reaches 
its  height  in  some  thirty-six  hours.  It  lasts  from  one  and  a  half  to  two 
and  a  half  days,  and  gives  way  by  a  rapid  defervescence  or  crisis,  except 
where  a  complication  exists.  These  changes  are  well  shown  in  Fig.  18. 
The  central  defervescence  in  measles  is  illustrated  in  Fig.  19.  Figs.  20 
and  21  are  interesting,  as  showing  the  exact  duration  of  incubation  in 
measles. 

Diagnosis. — The  recognition  of  measles  depends,  first,  on  the 
exanthem  or  rash ;  secondly,  upon  the  mucous  membrane  symptoms,  and 
the  characters  of  the  fever  (the  behaviour  of  the  temperature) ;  thirdly, 
upon  a  consideration  of  the  existing  epidemic  and  the  exposure  of  the 
patient  to  the  virus  of  measles. 

The  disease  may  be  confounded  with  Eotheln  (rubella),  scarlet  fever, 
variola,  varicella,  simple  roseolar  rashes,  and  typhus  fever. 

The  most  common  error  of  diagnosis  is  between  measles  and  smallpox, 
but  the  development  of  the  pustular  rash  of  the  latter  sets  the  question  at 
rest.  At  the  beginning,  also,  confluent  smallpox  presents  an  eruption  on 
the  second  day,  compared  with  the  fourth  or  fifth  day  in  measles.  The 
papules  of  smallpox  are  hard  and  shotty ;  those  of  measles  are  soft  and 
velvety.  The  following  method,  called  the  "  Grisolle  sign,"  is  a  certain 
means  of  diagnosis.  If  upon  stretching  an  affected  portion  of  the  skin  the 
papule  becomes  impalpable,  the  eruption  is  caused  by  measles ;  if,  on  the 
contrary,  the  papule  is  still  felt  when  the  skin  is  drawn  out,  the  eruption 
is  the  result  of  smallpox. 

Prognosis. — This,  in  primary  and  uncomplicated  measles,  is 
thoroughly  favourable.  The  mortality  varies  greatly.  Sometimes  only  2 
or  3  per  cent,  of  the  patients  die ;  occasionally  the  death  rate  reaches  the 
alarming  figure  of  50  per  cent.  Measles  is  mild  in  sucklings  under  6 
months  old;  it  becomes  severe  at  the  first  dentition,  and  is  sometimes  very 
severe  in  adults.  In  pregnancy  it  is  dangerous.  It  is  most  fatal  among 
the  illTnourished,  rachitic,  or  tuberculous  denizens  of  a  large  city. 

Unfavourable  symptoms  are  great  weakness  and  excitement  from  the 
outset ;  a  hot,  dry  skin ;  a  hard  and  rapid  pulse  ;  quick,  laboured  respira- 
tion, with  a  short  cough ;  early  fading  of  the  rash.  By  far  the  most  fatal 
complication  of  measles  is  bronchitis  in  its  severer  forms. 

Treatment. — Little  can  be  done  to  prevent  the  spread  of  measles, 
because  it  is  infectious  from  the  start,  while  the  first  case  in  a  household 
may  be  mistaken  for  a  severe  feverish  cold.  When  a  person  has  been 
exposed  to  the  infection,  he  cannot  be  pronounced  safe  within  sixteen 
days  at  least.  A  convalescent  from  measles  should  not  be  declared  free 
from  infection  until  three  or  preferably  four  weeks  have  elapsed  from  the 
first  symptoms. 


i68 


GENERAL  DISEASES. 


As  regards  curative  treatment,  Hilton  Fagge  aptly  points  out  that 
the  general  plan  of  treatment  in  measles  and  in  scarlatina  is  the  same, 


Day  of 
Disease 

4 

5 

6 

7 

8 

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10 

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13 

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15 
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Fig.  20. — Measles  after  scarlatina. 


for  in  neither  of  these  maladies  have  we  any  specific  method  of  dealing 
with  the  malady  itself."  A  mild  equable  atmosphere  is  essential  (60°  to 
65°  F.).     The  steam-kettle  should  be  used  in  winter.     Ventilation  should 


Dag  of 
Disease 

2 

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Fig.  21. — Measles  after  scarlatina. 


be  draughtless.  Children  must  be  watched  at  night,  lest  they  should 
throw  off  their  bed-clothes.  The  hands  and  face  may  be  washed  daily, 
and  the  whole  surface  may  be  cautiously  sponged  and  afterwards  oiled — 


S  CARL  A  TINA — S  CARLE  T  FE  VER.  1 6  9 

liniment  of  camphor,  a  weak  carbolised  oil  or  soft  paraffin,  or  hazeline 
cream  being  used  for  the  purpose.  Shelly  reports  unfavourably  on 
eucalyptus  inunction.  All  exposure  to  cold  must  be  carefully  avoided 
until  catarrhal  symptoms  have  passed  away.  In  convalescence,  fresh  air, 
driving  in  the  open  country,  and  change  of  air  to  the  seaside,  or  some 
sheltered  inland  health  resort,  are  desirable.  Among  drugs  suitable  for 
convalescents  from  measles  are  quinine,  saccharated  carbonate  of  iron, 
cod-liver  oil  with  saccharated  solution  of  lime,  chloride  of  calcium,  and 
syrup  of  the  lactophosphate  of  calcium.  The  skill  of  the  physician  is 
often  taxed  to  the  uttermost  in  the  treatment  of  the  complications  of 
measles. 

In  malignant  measles,  Dieulafoy  recommends  a  bath  at  2G°  C.  (78"-8  F.) 
for  twelve  minutes,  with  cold  affusion  to  the  head.  The  cold  bath  re- 
establishes the  secretion  of  urine,  the  skin  becomes  soft,  and  temperature 
falls. 

In  initial  convulsions  Trousseau's  advice  is  excellent — "Wait,  avoid 
boisterous  practice."  A  warm  bath  may  be  given,  or  compression  of  the 
carotids  may  be  practised,  in  the  way  recommended  by  Trousseau,  the 
common  carotid  artery  on  the  side  of  the  neck,  opposite  to  the  side 
convulsed,  being  pressed  upon  for  some  minutes  at  a  time. 

In  false  and  true  croup,  the  patient  should  be  placed  in  a  croup  tent, 
and  for  twenty  or  twenty-five  minutes  relays  of  sponges  soaked  in  hot 
water  may  be  applied  to  the  neck  and  throat.  In  suffocative  catarrh,  hot 
poulticing  does  good,  and  the  chest  may  be  wrapped  in  cotton-wool  or 
French  wadding,  after  rubbing  with  chloroform  and  ammoniated  camphor 
liniment.     Inhalations  of  oxygen  should  be  tried. 

Diarrhoea  is  often  checked  by  good  nursing  and  suitable  dieting.  A 
teaspoonful  dose  of  a  mixture  composed  of  five  drops  each  of  glycerin  of 
carbolic  acid  and  tincture  of  chloroform  and  morphine  in  cinnamon  water 
may  be  given  occasionally,  except  to  a  very  young  child.  If  colitis  occurs, 
albuminous  enemata  are  of  use. 

Ophthalmia  and  glandular  enlargements  require  constitutioiial  treat- 
ment— a  generous,  wholesome  dietary,  with  milk,  eggs,  cod-liver  oil,  and 
such  drugs  as  iron  and  quinine,  iodide  of  iron,  chloride  of  calcium,  and 
arsenic. 

Should  stimulants  be  required,  white-wine  whey,  brandy  and  warm 
milk,  or  egg-flip  will  be  most  suitable  for  children. 

J.  W.  MOOEE. 


SCAEEATINA— SCAELET  EEVEE. 

Syn.,  Lat.,  Fcbris  Rubra;  Er.,  Fttvre  rouge — Scarlatine ;  Ger., 
Scharlachfieber ,  or  shortly,  Scharlach. 

An  acute,  specific,  infectious  fever,  characterised  by  a  sudden  onset, 
with  vomiting,  rigors,  and  prostration ;  early  and  persistent  sore-throat, 
deep  injection  of  the  mucous  membranes  of  the  throat,  which  are  swollen 
and  inflamed,  very  rapid  pulse  rate,  and  high  fever ;  and  especially  by 
the  appearance  on  the  skin  after  a  few  hours  of  a  minutely  punctiform 
scarlet  rash,  which  is  most  intense  on  the  third  day,  and  afterwards 
fades  gradually,  to  be  succeeded  by  profuse  desquamation  of  the  cuticle 


170 


GENERAL  DISEASES. 


in  both  small  and  large  flakes.  A  specific  nephritis  is  a  not  uncommon 
complication  or  sequela.  Three  varieties  of  the  disease  are  recognised, 
namely,  simple,  anginose,  and  malignant  scarlatina. 

History. — The  origin  and  native  habitat  of  scarlet  fever  are  unknown. 
It  is  most  widely  distributed  on  European  soil,  especially  in  the  north- 
western and  northern  countries.  Its  diffusion  in  Africa  and  Asia  is 
limited.  It  is  rare  in  India,  unknown  in  Japan.  In  1848  it  broke  out  in 
Australasia,  where  it  generally  assumes  a  mild  type.     Its  first  outbreak  on 


percent 

Ja 

n. 

Feb. 

Mar. 

Apr 

May 

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July 

Aug 

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Oct. 

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60 

Fig.  22. — Scarlatina  mortality  curve. 

North  American  soil  took  place  in  1735,  when  it  broke  out  in  Kingston, 
Massachusetts,  and  overran  the  New  England  States  within  a  few  years. 
Not  until  1830  did  it  become  diffused  over  South  America. 


rcent 

Jan. 

Feb. 

Mar. 

Apr 

May 

June 

July 

Aug 

Sept. 

Oct. 

Nov 

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SO 

Fifi.  23. — Enteric  fever  mortality  curve. 

The  area  of  prevalence  of  scarlet  fever  is  much  smaller  than  that  of 
smallpox  or  of  measles.  Its  epidemics  arise  at  long  intervals  of  ten,  or 
even  twenty,  years.  It  shows  extreme  variation  in  severity — the  death- 
rate  being  almost  nil,  or  only  from  3  to  5  per  cent.,  in  some  outbreaks,  but 
rising  to  30  per  cent,  or  more  in  others — so  widely  does  the  epidemic 
constitution  vary. 

Etiology. — Climate  does  not  play  a  prominent  part  as  a  predispos- 
ing cause,  while  season  does.  Scarlatina  tends  to  increase  during  the 
second  half  of  the  year,  attaining  its  maximal  prevalence  in  the  fourth 


SCARLATIXA — SCARLET  FEVER. 


171 


quarter.  When  the  mean  temperature  rises  much  above  50°  F.,  scarlatina 
spreads ;  a  fall  of  mean  temperature  below  this  critical  point  in  autumn 
checks  its  prevalence.  Diphtheria  and  typhoid  fever  obey  the  same  law  of 
seasonal  prevalence.  The  facts  relating  to  scarlatina  and  enteric  fever 
are  shown  in  Figs.  22  and  23,  based  on  returns  of  the  registrar-general  for 
England  for  a  long  series  of  years.  Tbe  curves  refer  to  deaths  in  London. 
The  close  accordance  in  the  two  diagrams  is  very  remarkable.  Traumatism 
is  a  predisposing  cause,  the  disease  being  conveyed  through  the  infection  of 
a  wound,  the  result  of  injury  or  operation.  Such  is  the  so-called  surgical 
scarlatina.  Sometimes  this  form  of  scarlatina  is  spurious  and  septicemic 
in  origin.  More  females  than  males  are  attacked.  Age  is  a  potent 
predisposing  cause,  for  the  disease  is  essentially  one  of  childhood  and 
adolescence.  Goodall  aud  "Washbourn  give  the  following  table,  which 
shows  the  number  of  admissions  and  deaths  at  various  ages  in  the  hospitals 
of  the  Metropolitan  Asylums  Board,  London,  from  1871  to  1894,  together 
with  the  percentage  fatality : — 


Ages. 

Cases  Admitted. 

Deaths. 

Fatality 
per  Cent. 

Under  5  years 

5  to  10     ,, 
10  „  15     „ 
15  „  20     „ 
20  „  25     „ 
25  ,,  30    ,, 
30  ,,  35     ,, 
35  „  40     „ 
40  and  upwards 

• 

23,072 

33,647 

14,399 

5,319 

2,509 

1,215 

665 

281 

243 

4,052 

1,789 

345 

139 

65 
38 
31 
16 
15 

17-6 
5-3 

2  4 
2-6 
2-6 
3-1 
4  7 
57 
•       6-2 

Total        .... 

81,350 

6,490                    8-0 

The  specific  character  of  the  poison  of  scarlet  fever  is  unquestionable. 
The  contagium  vivum  is  singularly  retentive  of  life,  and  is  most  active. 
"The  virus  may  be  conveyed  by  fomites,  such  as  articles  of  dress,  bedding, 
carpets,  furniture,  and  even  letters.  It  may  also  be  inhaled,  swallowed  in 
water  or  milk,  or  carried  by  means  of  domestic  animals,  such  as  dogs  and 
cats.  Scarlatina  may  be  inoculated  by  means  of  the  blood,  the  epidermic 
scales,  and  the  serum  from  cutaneous  vesicles.  The  urine  also  is  believed 
to  be  infective. 

Klein  cultivated  a  streptococcus  from  the  blood  of  patients  during 
the  acute  febrile  stage  of  scarlatina.  The  same  streptococcus  was  found 
in  connection  with  an  eruptive  (ulcerative)  disease  on  the  teats  and 
udders  of  milch  cows,  at  Hendon,  in  1886.  To  the  consumption  of  the 
milk  from  these  cows  an  extensive  outbreak  of  scarlet  fever  in  the  north 
of  London  was  definitely  traced  by  Power.  This  micro-organism — the 
Streptococcus  scarlatina? — grows  slowly  on  gelatin,  in  opaque  wbite  colonies, 
and  does  not  liquefy  the  gelatin.  When  grown  in  milk,  it  coagulates  or 
curdles  it.  Cultivated  in  broth,  it  forms  long  and  exquisite  chains.  This 
microbe  apparently  conforms  to  Koch's  law,  and  is  therefore  regarded  as 
specific  by  Klein.  Thus  it  may  be  found  in  many  cases  of  scarlatina  ;  it 
can  be  cultivated  outside  the  human  body  in  suitable  media,  as  above — 
gelatin,  milk,  broth  ;  and  its  pure  cultures  possess  the  power  of  setting  up 
a  disease  in  animals,  resembling  scarlatina. 


172  GENERAL  DISEASES. 

Sternberg,  however,  considers  that  the  specific  infective  agent  in 
scarlet  fever  has  not  been  demonstrated.  In  the  secondary  affections, 
attended  by  suppuration,  one  or  other  of  the  common  pyogenic  micrococci 
is  usually  found,  and  is  doubtless  the  cause  of  the  local  inflammatory 
process.  Crajkowski  (1895)  found  a  diplococcus  present  in  comparatively 
small  numbers  in  the  blood  of  fifteen  scarlatina  patients.  He  does  not, 
however,  claim  for  this  diplococcus  a  specific  character. 

Morbid  anatomy  and  pathology. — The  blood  is  darkened  in 
colour,  thin,  and  generally  contains  an  excess  of  white  blood  corpuscles. 

The  cutis  of  the  scarlet  fever  skin  is,  according  to  Unna,  character- 
ised by  an  enormous  paralytic  dilatation  of  the  blood  vessels.  The 
capillaries  of  the  papillary  body,  as  well  as  of  the  cutis  proper,  are  all 
distended,  as  if  by  a  forcible  arterial  injection ;  the  cutaneous  vessels,  from 
the  lower  cutis  margin  onwards,  are  almost  all  of  equal  calibre.  The  fact 
that  this  great  dilatation  of  vessels  is  found  everywhere,  even  on  pieces 
taken  from  the  cadaver,  points  to  a  maximal  vascular  paralysis  at  the 
height  of  scarlet  fever.  All  signs  of  marked  cutaneous  oedema  are  absent, 
although  the  scarlet  fever  skin  is  "  puffy,"  owing  mainly  to  the  overfilling 
of  its  vessels  with  blood.  In  the  epidermis  we  find,  even  at  the  height  of 
the  rash,  an  abnormal  development  of  its  horny  layer ;  this,  later  on,  in 
different  ways,  leads  to  scaling,  while  the  prickle  layer  shows  neither 
oedema  nor  emigration  of  white  blood  corpuscles.  The  process  of  desqua- 
mation may  involve  the  nails  of  the  fingers  and  toes,  and  the  hair  may 
fall  out.  Warts  have  been  known  to  drop  off  after  scarlet  fever.  Unna 
holds  that  the  epidermic  changes  are  much  more  easily  explained  as  direct 
specific  actions  of  the  poison  than  as  the  hurtful  results  of  a  simple 
dermatitis. 

In  the  intestines  the  appearance  known  as  psorenterie  is  caused  by 
swelling  and  prominence  of  Brunner's  and  Lieberkuhn's  glands,  as  well  as 
of  the  solitary  follicles  and  Peyer's  patches.  In  the  kidneys  a  catarrhal 
condition  is  found  early  in  the  disease ;  a  true  parenchymatous  nephritis 
sets  in  later.  In  a  still  more  advanced  stage,  an  interstitial  nephritis  may 
supervene.  The  heart  muscle  suffers  severely.  Its  fibres  are  the  seat  of  an 
acute  molecular  disintegration,  to  which  have  been  given  the  various  names 
of  acute  parenchymatous'  myocarditis,  acute  parenchymatous  degeneration, 
albuminous  degeneration,  febrile  softening  of  the  heart,  infectious  myo- 
carditis. The  change  may  be  the  result  of  the  specific  action  of  the  fever 
poison,  or  of  the  pyrexia,  or  of  both,  on  the  protoplasm.  There  is  a  con- 
flict of  opinion  as  to  whether  the  condition  is  inflammatory,  or  merely 
degenerative.  As  regards  the  symptoms,  cardiac  failure  is  the  chief  evi- 
dence of  this  condition  of  the  endocardium. 

Symptomatology. — Cases  of  scarlatina  are  arranged  under  three 
headings — 

Scarlatina  simplex,  or  mild  scarlet  fever,  in  which  the  disease  runs 
its  course  without  complications  or  untoward  sequelae,  terminating  in  an 
uninterrupted  convalescence. 

Scarlatina  anginosa,  in  which  the  affection  of  the  throat  is  severe,  and 
the  cervical  glands  are  sharply  engaged. 

Scarlatina  maligna,  in  which  extreme  nervous  prostration,  with  its 
attendant  "  ataxic "  or  "  typhoid "  symptoms,  is  the  most  striking  and 
ominous  phenomenon. 

Incubation. — This  period  is  very  short,  probably  never  exceeding  a 
week,  and  rarely  lasting  so  long.     It  may  be  only  twenty-four  hours,  but 


SCAR  LA  TINA — S  CARLE  T  FE  VER.  1 7  3 

on  the  average  it  varies  from  three  to  five  days.  Consequently,  a  person 
who  has  been  exposed  to  the  poison  of  scarlatina,  and  does  not  sicken  after 
a  week's  quarantine,  may  be  pronounced  safe.  This  stage  of  latency  may 
be  unattended  by  symptoms,  or  towards  its  close  there  may  be  slight 
headache,  malaise,  lassitude,  and  loss  of  appetite. 

Invasion. — This  pre-eruptive,  prodromal,  or  initial  stage  is  shorter  in 
scarlatina  than  in  any  other  fever.  It  is  most  commonly  only  twenty- 
four  hours  in  duration.  The  onset  is  abrupt.  In  children,  the  earliest 
symptoms  are  usually  vomiting,  diarrhoea,  rigors,  or  a  convulsion — the 
last  named  a  sign  of  danger.  In  adults,  sore  throat  ushers  in  the  attack. 
It  is  accompanied  by  chilliness  or  rigors,  headache,  malaise,  and  prostra- 
tion. Pulse  and  temperature  rise  quickly.  The  rapidity  of  the  pulse — 
140  to  160  beats  a, minute — is  almost  pathognomonic  of  scarlatina.  The 
skin  is  hot  and  dry,  the  pungent  heat  being  like  that  of  acute  pneumonia. 
The  tonsils,  soft  palate,  and  uvula  are  deeply  injected,  plum-coloured,  and 
swollen.  The  cervical  and  submaxillary  glands  also  are  usually  engaged, 
but  the  Schneiderian  mucous  membrane  and  conjunctivae  generally  escape. 

Eruption. — The  rash  may  be  detected  very  early  on  the  sides  of 
the  neck  and  over  the  chest,  and  near  the  larger  joints.  It  after- 
wards spreads  to  parts  of  the  face,  the  abdomen,  and  the  limbs.  The 
centre  of  the  chin  and  a  zone  round  the  mouth,  as  well  as  the  scalp,  usually 
remain  free  from  the  rash.  So  also  do  the  palms  of  the  hands  and  soles 
of  the  feet.  The  eruption  consists  of  minute  red  dots,  with  surrounding 
paler  halos,  which  run  together,  causing  a  general  or  patchy  suffusion  of 
the  skin  of  a  bright  scarlet  colour,  which  suggested  to  Sir  Thomas  Watson, 
a  comparison  to  a  boiled  lobster.  The  eyelids,  cheeks,  hands,  and 
feet  commonly  swell  slightly.  The  contractile  power  of  the  cutaneous 
arterioles  being  increased,  on  pressure  a  white  stripe  or  streak  develops, 
and  lasts  for  a  few  moments.  This  is  the  so-called  Tache  scarlatinale,  a 
diagnostic  sign  of  some  value. 

Sometimes  a  millet-seed  rash  of  tiny  vesicles  is  observed.  These 
become  filled  with  a  milky  fluid  after  thirty-six  to  forty-eight  hours.  In 
other  cases  the  rash  is  blotchy,  macular,  or  papular.  In  complicated  or 
malignant  cases  the  rash  is  badly  developed,  or  fails  to  appear.  After 
two  or  three  days  the  eruption  fades  slowly,  leaving  persistent  petechial 
lines  in  the  folds  in  front  of  the  elbows,  in  the  armpits,  groins,  and 
popliteal  spaces.  These  streaks  may  help  in  diagnosis.  The  fever  runs 
high  in  the  eruptive  stage,  and  the  pulse  beats  fast.  The  tongue  is  at 
first  coated  with  a  thick,  creamy,  white  fur,  through  which  the  en- 
larged papillaa  project  as  little  scarlet  protuberances.  The  fur  is  shed 
quickly,  leaving  the  tongue  red  and  raw,  resembling  a  ripe  strawberry. 
Hence,  the  expressions  strawberry  tongue,  and  cat's  tongue.  Defer- 
vescence is  gradual,  by  lysis,  extending  over  from  two  to  eight  days. 
The  temperature  spikes  somewhat — rising  in  the  evenings,  falling  in  the 
mornings. 

Desquamation. — The  process  called  "  peeling  "  sets  in  on  the  neck  and 
chest,  between  the  sixth  and  ninth  days.  Then  it  affects  the  limbs, 
hands,  and  soles  of  the  feet.  Branny  scales  come  off  from  the  face,  flakes 
of  dead  cuticle  from  the  trunk,  and  sometimes  gloves  of  skin  from  the 
hands  and  feet — even  the  nails  may  occasionally  be  shed.  Wilks  drew 
special  attention  to  an  atrophic  transverse  furrow  or  groove  in  the  nails 
of  scarlet  fever  patients.  On  the  body,  desquamation  begins  by  an  eleva- 
tion of  the  horny  layer   of   the   epidermis   into   little   circular   mounds. 


174 


GENERAL  DISEASES. 


The  tops  of  these  are  rubbed  off  or  split,  leaving  ring-shaped  free  edges. 
The  rings  spread  outwards,  and  coalesce  with  each  other. 

In  this  stage,  albuminuria  often  makes  its  appearance,  one  reason  being 


Day  of 
Disease 

1 

2 

3 

4 

6 

G 

7 

8 

9 

10 

11 

12 

104° 
103° 

102 

101° 

100 

99 

Normal 
98 

97 

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Day  of 

Disease 

3 

4 

5 

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104° 
103 

102 

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100° 

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98° 

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- 

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— 

Fig.  24. — Simple  scarlatina. 


Fig.  25. — Simple  scarlatina. 


the  shedding  of  the  dead  tubal  epithelium  in  the  kidneys,  in  consequence 
of  which  albumin  escapes  into  the  urine.  The  duration  of  desquamation 
is  indefinite — in  some  cases  it  lasts  for  a  fortnight  only ;  in  others,  for 

several  weeks,  perhaps  for 
months. 

Relapse  is  a  very  in- 
frequent occurrence,  but  un- 
doubted examples  are  from 
time  to  time  recorded.  It 
may  be  caused  by  auto- 
infection,  or  by  re-infection 
through  a  prolonged  sojourn 
in  scarlatina  wards. 

Irregular  or  aberrant 
forms  of  scarlatina  often 
present  themselves.  Of  the 
rudimentary  or  abortive  and 
therefore  mild  forms,  the 
most  frequent  is  simple 
scarlatinal  angina,  or  sore 
throat.  We  also  meet  dis- 
guised or  latent  scarlet  fever 
— the  form  to  which  Trous- 
seau gave  the  name  of 
Scarlatine  fruste. 
In  marked  contrast  to  these  mild  forms,  we  often  come  across  that 
severe  variety  called  Scarlatina  anginosa.  Pain  and  stiffness  about  the 
jaws  are  early  symptoms.  The  throat  feels  raw,  deglutition  is  difficult  and 
painful,  there  is  hoarseness,  the  tonsils  are  swollen,  of  a  deep  purple 
hue,    and  coated  with   small,  whitish   specks   of   exudation.      Offensive 


D?seas:3      4       5       6       7       8      9      10      II       12     13      14     15      16     17      18 

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Fig.  26. — Anginose  scarlatina. 


SCARLATINA — SCARLET  FEVER 


i75 


sanious  discharges  take  place  from  the  nostrils,  irritating  the  neighbour- 
ing skin,  the  breath  is  foetid,  the  voice  becomes  nasal,  liquids  return  by  the 
nostrils,  and  deafness  may  occur,  owing  to  extension  of  the  disease  through 


oSUL     1        2       3       4       5       6      7       3       9      *0     1 

12     13     14     15      16     17     18     19    20    21     22 

23    24    25    26   27 

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Fig.  27. — Ataxic  scarlatina. 

the  Eustachian  tubes.  The  cervical  glands  swell  enormously,  and  diffuse 
cellulitis  of  the  neck  may  cause  the  very  fatal  condition  known  as  "  tippet 
neck."  Diphtheria  is  a  not  uncommon  complication  in  this  form  of 
scarlatina.  The  tonsils  and  soft 
palate  may  undergo  necrosis  in 
patches   and  slough  away. 

The  term  Scarlatina  maligna  is 
reserved  for  two  terrible  varieties  of 
the  malady,  namely,  ataxic  scarlatina 
and  hfemorrhagic  scarlatina.  They 
constitute  the  Scharlachtyphus  of 
Hebra. 

Nervous  or  ataxic  scarlet  fever  is 
ushered  in  with  rigors,  convulsions, 
and  even  tonic  spasms,  with  trismus, 
incessant  vomiting,  and  diarrhoea, 
wakefulness,  agitation,  and  restless- 
ness with  delirium,  and  hyperpy- 
rexia— 110°-3  F.  (43°-5  C.)  was  ob- 
served by  Wunderlich.  Ataxic 
symptoms  quickly  follow — muscular 
tremors,  plucking  at  the  bedclothes, 
the  coma  vigil  described  by  Jenner, 
dilated  pupils,  coma,  quick  shallow 
breathing,  extreme  feebleness  of  the  heart's  action,  and  profuse  cold  or 
clammy  sweating.  In  these  cases  the  rash  is  badly  developed,  and  life 
ebbs  quickly. 

In  the  very  rare  form  known  as  haemorrhagic  scarlatina,  the   rash 


Dug  0/ 
Disease 

3 

4 

5 

6 

7 

3 

9 

10 

M  1 

2 13 1 

4     15 

16 

106° 
105° 

104° 

103° 

02° 

101° 

100° 

99° 

■Vormal 
98° 

I 

1    \ 

R 

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1 

Fig.  28. — Malignant  scarlatina. 


i;6  GENERAL  DISEASES. 

comes  out  late  and  imperfectly.  Its  colour  is  dark,  and  reddish  brown 
points  of  haemorrhage,  with  petechias  and  vibices,  are  found  scattered  over 
the  surface  in  children,  less  extensively  in  adults.  The  tonsils  and  gums 
are  dark-coloured,  and  heernorrhages  take  place  from  the  mucous  mem- 
branes, especially  of  the  nose,  colon,  and  urinary  organs.  In  women, 
menorrhagia  may  occur.  Pleuritic  or  pericardial  extravasations  of  blood 
may  take  place. 

Complications. — The  chief  complications  of  scarlatina  are — diphtheria, 
acute  rheumatic  arthritis,  and  inflammations  of  the  serous  membranes, 
acute  desquamative  nephritis,  pleuritis  with  purulent  effusion,  bubonic 
swellings  in  the  neck.  In  convalescence,  the  sequelae  most  likely  to 
occur  are — pyaemia,  boils  and  abscesses,  otitis,  affections  of  the  eye,  eczema, 
and  chorea,  or  St.  Vitus's  dance. 

Acute  desquamative  nephritis  generally  sets  in  towards  the  close  of 
the  first  week.  It  may  appear  in  the  second  week,  or  in  convalescence. 
It  is  ushered  in  with  suppression  of  urine,  or  hematuria,  oedema  of  the 
eyelids,  pallor,  thixst,  and  high  temperature.  If  passed  at  all,  the  urine 
is  scanty,  highly  albuminous,  of  high  specific  gravity  (1020—1030),  smoky 
appearance,  and  acid  reaction.  Under  the  microscope,  altered  red  blood 
corpuscles,  and  granular,  bloody,  and  epithelial  tube  casts  are  visible.  The 
affection  may  terminate  in  recovery  (the  urine  becoming  copious,  clear, 
and  of  low  density),  in  death  with  convulsions,  or,  very  rarely,  in  chronic 
general  nephritis. 

Temperature. — The  behaviour  of  the  temperature  in  scarlatina  is  less 
typical  than  it  is  in  smallpox  or  measles.  At  the  outset  it  rises  rapidly 
and  continuously  in  a  few  hours  to  103°  or  104'  F.  "With  the  coming  out 
of  the  rash  a  further  rise  is  observed  to  105°,  but  seldom  in  cases  which 
end  favourably  to  105°-8  or  upwards.  As  a  rule,  the  intensity  of  the  fever 
bears  a  tolerably  close  relation  to  that  of  the  rash.  With  the  fading  of 
the  rash  defervescence  begins.  It  may  be  sudden,  but  generally  it  is  pro- 
tracted, extending  over  from  three  to  eight  days.  The  evening  readings 
are  higher  than  the  morning  ones.  Complications  of  course  modify  the 
temperature  range.  The  thermometer  may  fall  below  normal  at  the  end 
of  defervescence,  and  other  collapse  symptoms  may  appear.  In  typhoid- 
scarlatina  the  temperature  may  present  a  subcontinuous  or  remittent  type. 
In  fatal  cases  hyperpyrexia  is  common.  The  series  of  temperature  charts 
(Figs.  24-28),  from  cases  under  my  own  observation,  is'  intended  to 
illustrate  the  behaviour  of  the  temperature  in  scarlatina  of  varying  types. 

Diagnosis. — We  have  to  distinguish  scarlatina  from  erythema,  small- 
pox, measles,  epidemic  rose  rash  or  rubella,  erysipelas,  tonsillitis,  diphtheria, 
and  acute  rheumatism. 

In  erythema  the  fever  is  slight ;  there  is  no  sore  throat,  glandular 
swelling,  kidney  affection,  or  desquamation.  Smallpox  could  only  at  the 
outset  be  mistaken  for  scarlatina.  The  adventitious  prodromal  rash,  and 
a  certain  amount  of  sore  throat,  may  cause  confusion  for  a  while.  In 
measles  the  early  angina,  the  strawberry  tongue,  and  the  glandular 
swellings  of  scarlatina  are  wanting,  while  the  catarrhal  symptoms  are 
characteristic.  The  diagnosis  between  scarlatina  and  rubella  is  often 
difficult.  In  the  latter  disease  the  rash  shows  on  the  face ;  it  fades  soon, 
the  fever  is  moderate,  the  pulse  rate  relatively  slow,  angina  is  trifling, 
and  the  occipital  glands  are  large  and  hard.  In  acute  tonsillitis,  cynanche 
tonsillaris,  or  quinsy,  one  tonsil  is  generally  more  engaged  than  the  other ; 
vomiting,  rash,  and    albuminuria   are   wanting.      Diphtheria,   seemingly 


SCARLATINA — SCARLET  FEVER.  177 

primary,  niay  really  be  complicating  scarlet  fever,  with  a  badly-developed 
rash.  Note  should  be  taken  of  any  prevailing  epidemic.  Acute  rheumatism 
usually  attacks  adolescents  or  adults.  It  is  distinguished  from  scarlet  fever 
by  its  symptoms  and  course,  by  its  profuse  acid  and  sour-smelling  perspira- 
tions, and  by  the  absence  of  the  glandular  swellings  and  renal  complica- 
tions of  scarlatina. 

Prognosis. — This  is  always  uncertain,  for  scarlet  fever  is  one  of  the 
most  treacherous  of  maladies.  Therefore,  a  guarded  opinion  should  be 
given,  no  matter  how  mild  the  attack  may  seem  to  be.  The  rate  of  mor- 
tality frequently  reaches  15  per  cent.  It  may  touch  25,  30,  or  even  40 
per  cent.  It  is  influenced  unfavourably  by  age,  social  status,  family  idio- 
syncrasy, pregnancy,  and  previous  ill  health.  Among  children  under  5 
years  of  age  it  is,  on  an  average,  nearly  20  per  cent.,  or  one  in  five, 
as  may  be  seen  in  the  table  on  p.  171.  In  a  given  case,  unfavourable  signs 
are — Hyperpyrexia,  dyspnoea,  extreme  rapidity  and  feebleness  of  the  pulse, 
early  collapse,  badly -developed  and  dark  -  coloured  rashes;  persistent 
vomiting  and  diarrhoea ;  delirium,  or  coma ;  sloughing  of  the  fauces, 
diphtheria,  purulent  arthritis,  and  other  severe  complications,  especially 
nephritis,  with  anuria  and  diffuse  cellulitis  of  the  neck. 

Treatment. — The  prophylaxis  of  scarlet  fever  is  not  attended  by 
the  vast  difficulties  which  beset  the  attempt  to  control  the  spread  of 
measles.  Breathing  time  is  allowed  the  physician  in  which  to  plan  and 
give  effect  to  precautionary  measures,  for  there  can  be  little  doubt  that 
the  poisonous  virus  is  shed  in  greatest  quantity  during  the  later  stages  of 
the  disease,  in  the  discharges  from  the  nose  and  throat,  in  the  motions  from 
the  bowels,  in  the  urine,  but,  above  all,  in  the  peeling  cuticle. 

All  known  drugs  are  without  avail  as  prophylactics,  and  we  have  not  as 
yet  discovered  a  specific  remedy  for  scarlatina.  The  only  effectual  pro- 
phylaxis consists  in  isolating  the  patients  from  those  who  are  unaffected 
as  early  and  as  completely  as  possible.  The  isolation  or  insulation  of  the 
sick  should  be  kept  up  until  desquamation  has  finally  ceased.  A  scarlatina 
patient  may  go  home  or  rejoin  school,  provided  he  and  his  clothes  have 
been  thoroughly  disinfected,  in  not  less  than  six  weeks  from  the  appearance  of 
the  rash,  if  desquamation  has  completely  ceased,  and  there  is  no  complaint 
or  sign  of  sore  throat,  or  of  discharge  from  the  nose  or  ears. 

The  term  curative  treatment  must,  in  the  absence  of  a  specific  for 
scarlatina,  be  taken  in  a  qualified  and  restricted  sense  to  express  the  meas- 
ures we  adopt  to  help  the  patient  safely  through  his  illness.  The  treatment 
must  be  largely  symptomatic,  and  directed  mainly  against  those  complica- 
tions and  sequelae  which  disturb  the  regular  progress  of  the  disease. 

The  sick-room  should  be  fresh  and  airy.  The  bed-covering  should  be 
light.  Very  little  furniture  should  be  allowed.  There  should  be  no  cur- 
tains or  carpets.  A  daily  toilet  is  a  necessity,  and  tepid  sponging  of  the 
whole  body  is  useful  and  refreshing.  Indeed,  warm  or  tepid  baths  may  be 
given  from  the  outset,  as  a  means  of  freeing  the  piatient  from  infection. 

The  bed-  and  body -linen  may  be  changed  as  often  as  required.  The  diet 
should  consist  of  weak  meat-broth,  chicken-broth,  gruel,  milk  (plain  or 
renneted,  or  peptonised,  or  mixed  with  aerated  water,  or  lime-water  in 
varying  quantity),  oranges,  and  cooked  fruits.  Cool,  refreshing  drinks, 
such  as  cold  spring  water,  lemonade,  acidulated  water,  are  to  be  given 
freely  and  at  short  intervals.  The  urine  should  be  examined  daily.  The 
hot-air  or. vapour-bath  may  be  used  if  albuminuria  is  present,  and,  during 
desquamation,  the  tepid  bath  will  be  found  both  grateful  and  beneficial. 
vol.  1. — 12 


178  GENERAL  DISEASES. 

It  may  be  given  daily,  and  followed  by  dry  rubbing  and  inunction  with 
weak  carbolised  oil  (1  to  2  per  cent.),  or  soft  paraffin,  or  camphorated  oil. 
Ten  grains  of  thymol  may  be  added  to  an  ounce  of  soft  paraffin,  or  simple 
ointment,  as  a  disinfectant.  Scarlatina  is  a  great  blood  destroyer,  and,  in 
convalescence,  iron  will  be  required,  as  well  as  change  of  air  to  the  moun- 
tains oT  the  seaside. 

In  scarlatina  anginosa,  the  cold-water  treatment  may  be  adopted  to 
reduce  hyperpyrexia.  Cold  baths,  the  wet  pack,  cold  douches,  the  internal 
administration  of  large  quantities  of  cold  water,  either  by  the  mouth  or 
by  enema,  all  absorb  a  large  amount  of  heat  from  the  body,  while  they 
rather  augment  the  formation  of  heat.  Hence  the  patient  is  not  depressed, 
and  does  not  become  collapsed.  The  constant  swallowing  of  fragments  of 
ice  is  grateful  and  effectual.  Cold  compresses  of  lint,  moistened  with 
water  and  glycerin,  should  be  wrapped  round  the  throat.  The  nostrils, 
mouth,  and  pharynx  should  be  frequently  washed  or  sprayed  with  a  dis- 
infectant, or  antiseptic  solution,  such  as  sulphurous  acid,  chlorine  water, 
permanganate  or  chlorate  of  potassium,  or  glycerin  of  carbolic  acid. 
Caustics  of  all  kinds,  in  my  opinion,  had  best  be  avoided.  Pain  may  be 
relieved  by  painting  with  a  solution  of  cocaine.  Quinine,  ferric  chloride, 
guaiacum,  carbonate  of  guaiacol,  salicylate  of  sodium,  and  tincture  of 
acetate  of  iron  with  glycerin,  are  among  the  most  useful  drugs.  Lastly, 
a  moderate,  sometimes  a  free,  allowance  of  stimulants  is  necessary. 

The  treatment  of  scarlatina  maligna  is  too  often  of  no  avail,  the  patient 
dying,  poisoned,  in  a  few  days  or  even  hours.  Ataxic  symptoms  must  be 
combated  by  the  free  administration  of  liquid  food  and  stimulants,  and 
by  the  exhibition  of  such  remedies  as  carbonate  of  ammonia,  quinine,  bark, 
iron,  camphor,  and  musk.  Derivation  to  the  surface  may  prove  of  use. 
It  is  carried  out  by  wrapping  the  lower  limbs  and  body  in  flannels  or  in 
cloths  wrung  out  of  mustard  and  hot  water,  or  by  the  warm  or  hot  bath ; 
or  by  the  cold  pack  and  cold  affusion,  followed  by  warm  wrappings ;  or  by 
applying  a  hot  flat-iron,  combined  with  a  mustard  bath  and  subsequent 
warm  wrappings.  In  the  hemorrhagic  variety  we  must  resort  to  general 
and  local  astringents.  Ice,  in  every  form  of  application  or  use,  is  an 
invaluable  remedy. 

The  awful  prostration  of  diphtheria  is  best  combated  by  food,  wine, 
diffusible  stimulants,  bark,  and  quinine,  or  iron.  The  antidiphtheritic 
serum  should  be  injected  hypodermically,  its  effect  being  closely  watched. 

The  rheumatic  affection  of  scarlatina  is  best  treated  like  ordinary  acute 
rheumatism,  salicin  and  the  salicylates  being  especially  useful  drugs  for 
internal  medication. 

In  acute  desquamative  nephritis,  the  patient,  clad  in  a  long  flannel 
night-dress  from  head  to  foot,  should  remain  in  bed,  wrapped  in  a  blanket. 
He  should  be  placed  on  a  mild,  unstimulating  diet  of  milk,  skimmed,  or  as 
buttermilk,  farinaceous  food,  and  light  broths.  Thirst  is  best  relieved  by 
copious  draughts  of  cold  water.  Dry  cupping  and  poulticing  over  the 
kidneys  will  do  good.  Local  depletion  by  leeching,  or  wet  cupping,  may 
be  practised  with  benefit  in  a  robust  patient.  The  bowels  must  be  kept 
open  by  hydragogue  cathartics.  Should  dropsy  supervene,  much  benefit 
will  be  derived  from  hot  air,  vapour,  or  even  warm-water  baths.  The  wet 
pack  may  be  used  to  promote  elimination  through  the  skin.  To  prevent 
uraemia,  full  doses  of  benzoate  of  sodium,  with  digitalis,  should  be  given. 
If  ursemic  convulsions  occur,  a  large  dose  of  sulphate  of  magnesium, 
well   diluted,   or   a   bolus   of   calomel   and  jalap,   may   be   administered. 


RUBELLA — ROSEOLA  EPLDEMLCA — RUBEOLA  NOTHA.     179 

Mercurials  should,  however,  as  a  rule,  be  avoided  in  this  affection.  The 
temples  may  be  dry-cupped,  or  leeched,  and  Trousseau's  plan  of  compressing 
the  common  carotid  artery  in  the  neck,  on  the  side  opposite  to  that  affected 
by  the  convulsions,  may  be  tried.  Other  means  of  relief  are  chloral  hydrate, 
with  the  bromides,  butyl  chloral,  inhalations  of  chloroform,  the  nitrites 
citrate  of  caffeine,  diuretin,  or  an  enema  of  black  coffee. 

In  convalescence  the  patient  should  wear  woollen  clothing  day  and 
night,  and  in  all  seasons.  The  Jaeger  system  is  both  popular  and 
efficient.  Iron,  quinine,  and  albuminous  food  are  indicated  in  this  stage. 
In  diffuse  cellulitis  of  the  neck,  early,  deep,  and  free  incisions  should  be 
practised,  except  in  young  children.  The  diseases  of  the  ear  in  scarlatina 
require  early  and  skilled  attention.  The  external  auditory  meatus  should 
be  kept  clean  and  free  by  gentle  syringing.  Douches  and  antiseptic  or 
detergent  gargles  should  be  used.  A  single  leech  applied  behind  the  ear 
relieves  intense  pain.  A  poultice  may  be  afterwards  applied,  and  the 
meatus  stuffed  with  oiled  cotton-wool. 

J.  W.  MOORE. 


RUBELLA— ROSEOLA  EPIDEMICA— RUBEOLA  NOTHA. 

Syn.,  Eng.,  German  Measles,  Epidemic  Rose  Bash,  Epidemic  Roseola,  Bastard 
Measles  ;  Er.,  Boseole  ;  Ger.,  Rotheln. 

A  specific  and  infectious  eruptive  fever,  distinct  and  separate,  of  its 
own  kind;  neither  a  hybrid  of  scarlet  fever  and  measles,  nor  a  modi- 
fied form  of  one  or  other  of  those  diseases,  Rotheln  breeds  true.  The 
disease  begins  suddenly,  after  an  incubation  of  about  twelve  days,  with 
ordinary  febrile  symptoms  of  moderate  intensity.  The  rash  appears 
on  the  first  or  second  day.  It  consists  of  rose-red  spots,  sometimes  so 
small  and  thickset  as  to  resemble  scarlatina,  at  other  times  larger  and 
discrete,  like  measles.  In  some  cases  the  rash  presents  both  characters 
in  different  parts  of  the  body.  There  are  slight  catarrhal  and  anginal 
symptoms.  Enlargement  and  induration  of  the  lymphatic  glands  in  the 
occipital  and  cervical  regions  is  a  constant  symptom.  The  febrile  move- 
ment is  brief,  and  recovery  is  generally  uninterrupted  and  complete. 

History. — The  first  British  writer  on  this  disease  was  Robert  Paterson 
of  Leith.  He  adopted  the  German  name  Rotheln,  which  is  now  being 
gradually  superseded  by  the  terms  epidemic  rose-rash  and  rubella.  To 
old  authors  this  eruptive  fever  was  known  by  various  names,  of  which 
roseola  and  Erytheme  ftigace  survive.  The  more  accurate  descriptions  of 
the  disease  date  from  the  middle  of  the  last  century  (Orlow,  1758).  Thomas 
described  two  epidemics  of  rubella,  which  occurred  in  Leipzig  in  1868  and 
1874.  In  the  year  1874,  also,  an  epidemic  was  observed  in  New  York  by 
Lewis  Smith. 

Etiology. — The  assumption  of  a  specific  roseola  is  based  chiefly  on 
the  fact  that  at  certain  times  epidemics  appear  in  which  individual  cases 
bear  a  causal  relation  to  one  another.  Again,  this  disease  affords  no  pro- 
tection against  either  measles  or  scarlatina,  whereas  it  does  protect  an 
individual  from  a  second  attack  of  itself.  Lastly,  it  may  attack  those  who 
have  lately  or  previously  passed  through  either  measles  or  scarlatina.  It 
is  especially  a  disease  of  childhood,  but  may  occur  in  adults  up  to  the  age 


180  GENERAL  DISEASES. 

of  40.  Very  young  children  enjoy  a  certain  immunity  from  it.  Trous- 
seau puts  the  case  clearly  and  well  when  he  asserts  that  rubella  bears  the 
same  relation  to  measles  and  scarlatina  that  chickenpox  does  to  smallpox. 
This  is  equivalent  to  saying  that  it  is  a  totally  distinct  disease.  As  regards 
seasonal  prevalence,  rubella  is  generally  most  common  in  spring — March  to 
June.  In  this  particular  it  more  closely  resembles  measles  than  scarlatina, 
which  latter  is  an  autumnal  malady.     It  is  infectious  from  the  outset. 

Morbid  anatomy  and.  pathology. — Analogy  suggests  that 
rubella  is  due  to  the  presence  of  a  specific  micro-organism.  Of  its  intimate 
nature  we  so  far  know  nothing.  The  poison  appears  to  have  a  special 
affinity  for  the  lymphatic  glands  and  skin.  The  mucous  membranes  are 
less  actively  involved. 

Symptomatology. — Incubation. — This  appears  to  vary  widely  in 
duration,  but  is  probably  twelve  days,  on  an  average. 

Invasion. — The  prodromal  symptoms  are  sometimes  absent  or  badly 
marked — attention  being  first  drawn  to  the  patient  because  a  rash  has  been 
found  upon  the  skin.  Usually,  however,  the  initial  phenomena  of  a  feverish 
attack  are  fairly  in  evidence.  Nausea  is  a  common  symptom,  and  rarely 
convulsions  may  occur. 

Eruption. — In  a  few  hours,  or  on  the  second  day,  the  rash  appears  on 
the  body,  thence  extending  to  the  legs.  It  may  show  itself  first  on  the  face 
and  neck,  down  the  back,  or  over  the  chest ;  most  often  it  is  like  the  rash 
of  measles,  less  frequently  it  is  scariatiniform.  The  compound  or  hybrid 
rash  has  been  seen  by  Kuttner.  It  consists  of  minute  red  papules  which 
coalesce  and  form  larger  irregular  patches,  without  assuming  the  horse-shoe 
or  crescentic  shape  of  the  rash  of  measles.  The  slightly  raised  rose-coloured 
spots  or  maculae  of  rubella  vary  in  size  from  a  mere  point  to  one-sixth  of 
an  inch  in  diameter.  Troublesome  itching  accompanies  the  eruption,  which 
fades  slowly,  leaving  dark  and  dirty  or  yellowish  stains  visible  for  five,  six, 
or  more  days. 

Simultaneously  with  the  rash,  there  is  a  mild  injection  and  inflamma- 
tion of  the  mucous  membranes  covering  the  buccal,  pharyngeal,  and  nasal 
surfaces,  and  of  the  conjunctivas. 

Lastly,  enlargement  and  induration  of  the  lymph  glands  is  an  almost 
pathognomic  sign  of  rubella.  The  glands  on  the  mastoid  processes,  and 
behind  the  sterno-mastoid  muscles,  as  well  as  those  of  the  posterior  chain 
below  the  occipital  protuberance,  are  particularly  affected.  The  bronchial 
glands  almost  certainly  share  in  this  pathological  change. 

Desquamation.— There  is  but  little  peeling  in  rubella.  In  several  of  my 
cases  there  was  slight  desquamation  on  the  bridge  and  at  the  sides  of  the 
nose;  in  one  case,  the  skin  was  shed  in  large  flakes,  as  in  scarlatina,  and 
even  the  nails  came  off. 

The  febrile  movement  is  usually  slight.  In  three  cases  observed  by 
myself,  the  maximal  temperatures  were  102°-4,  98°'2,  and  99°-8  respect- 
ively. 

Complications  and  sequelae  may  almost  be  said  not  to  exist  in  rubella. 
In  one  instance,  profuse  and  repeated  haemoptysis  seemed  to  have  been 
brought  about  by  caseation  and  tuberculisation  of  enlarged  bronchial  glands 
after  an  attack  of  this  disease. 

Diagnosis. — Eubella  derives  its  chief  importance  from  so  often  and 
so  closely  resembling  measles  or  scarlatina.  The  subfebrile  temperature  of 
the  early  stage  precludes  the  possibility  of  scarlatina  and  the  probability 
of  measles.     The  early  appearance  of  the  rash  distinguishes  it  from  that  of 


PERTUSSIS —  WHOOPING-  CO  UGH  1 8 1 

measles,  while  its  usual  "  measly  "  character  aids  the  diagnosis  from  scarla- 
tina. The  anomalous  combination  of  the  coryzal  symptoms  of  measles,  with 
the  sore  throat  of  mild  scarlatina,  should  excite  suspicion  as  to  the  probable 
presence  of  rubella. 

From  ordinary  rose-rash,  or  roseola,  and  also  from  erythema,  rubella  is 
distinguished  by  its  pyrexia,  enlarged  glands,  and  threat  symptoms.  The 
rash  may  be  confounded  with  the  early  accidental  rashes  of  smallpox,  but 
the  character  of  the  prevailing  epidemic  and  the  subsequent  history  of  the 
case  should  clear  up  the  diagnosis. 

Prognosis. — Once  the  diagnosis  is  made,  we  may,  in  most  cases, 
pronounce  an  entirely  favourable  opinion.  Yet  rubella  may  occasion 
grave  disturbance  or  even  death  in  a  delicate  subject.  The  enlargement 
of  the  lymph  glands  also  may  have  far-reaching  and  untoward  effects  upon 
the  patient's  health  and  constitution. 

Treatment. — The  patient  should  be  kept  in  bed  while  the  fever  lasts, 
protected  against  cold,  and  suitably  fed.  Tepid  or  cool  sponging  will 
relieve  itching.  "Watch  should  be  kept  upon  any  catarrh  of  the  pharynx 
or  air  passages.  Warm  baths  are  most  useful  in  convalescence.  Good 
nursing  and  sound  common  sense  alone  are  wanting  to  tide  a  patient  over 
an  attack  of  what  has  been  called  "  this  lightest  of  the  acute  exanthema. " 

J.  W.  MOOSE. 


PERTUSSIS— WHOOPING-COUGH. 

Syn.,  Old  Eng.,  Chincough  ;  Scots.,  Kinkhost,  or  Kinkhaust ;  Fr.,  Coqueluche  ; 
Ger.,  Keuchhusten,  or  Keichhusten,  Stickhusten  ;  Dutch,  Kinkhoest. 

An  acute  specific  disease  of  childhood  in  particular,  highly  infectious, 
running  its  course  in  six  or  eight  weeks,  seldom  recurring,  characterised 
especially  by  spasmodic  fits  of  coughing,  which  often  terminate  in  an 
attack  of  vomiting,  and  in  the  expulsion  of  a  quantity  of  viscid  mucus. 
The  early  symptoms  are  those  of  a  common  cold  or  catarrh,  with  some 
feverishness,  but  even  in  this  stage  the  cough  is  harsh,  brassy,  and 
spasmodic.  In  and  after  the  second  week  the  paroxysms  of  coughing 
recur  at  longer  or  shorter  intervals,  and  consist  of  a  rapid  series  of  forcible 
and  noisy  expirations,  during  which  the  face  flushes,  terminating  in  a  pro- 
longed shrill  inspiration  or  whoop.  Long  after  the  disease  has  passed 
away,  its  peculiar  cough  may  present  itself  in  the  course  of  an  accidental 
"cold"  or  simple  bronchial  catarrh.  Whooping-cough  is  apt  to  be  com- 
plicated by  bronchitis  and  catarrhal  pneumonia. 

History. — The  earliest  authentic  notice  of  whooping-cough  is  said  to 
date  from  the  middle  or  towards  the  end  of  the  sixteenth  century.  It 
was  described  by  Sydenham  under  the  names  Pertussis  infantum  and 
Tussis  puerorum  convulsiva.  Glisson  called  it  Tussis  clangosa.  The  ©npt&bug 
j3rj%  of  Hippocrates  and  Galen  was  probably  whooping-cough.  Hoffmann 
translated  this  Greek  term  into  Latin  as  Tussis  ferina.  As  regards  the 
Scots  term,  host  means  cough,  and,  according  to  Skeat,  "  a  kink  is  a  catch 
in  the  breath,  nasalised  form  of  a  base  kik,  to  gasp." 

At  .the  present  day,  whooping-cough  is  met  with  in  nearly  all  parts  of 
the  habitable  globe.  Into  Australasia  and  Polynesia  it  was  introduced  within 
comparatively  recent  times,  even  still  it  is  of  infrequent  occurrence  in 


1 82  GENERAL  DISEASES. 

Iceland  and  the  Faroe  Isles.  Its  native  habitat  is  by  no  means  as  exten- 
sive as  its  present  geographical  distribution.  It  is  a  fatal  disease  in  badly 
nurtured  children  of  tender  years,  particularly  infants. 

Etiology. — Whooping-cough  occurs  in  frequent  and  either  localised 
or  wide-spreading  epidemics,  chiefly  in  spring  and  early  summer  (March 
to  May  or  June) — at  least  in  these  countries.  The  outbreaks  spread  along 
lines  of  intercommunication  and  through  schools,  until  they  die  out  for 
want  of  fuel  in  the  form  of  susceptible  children.  Other  things  being  equal, 
the  disease  is  less  common  and  less  severe  in  tropical  and  subtropical 
climates  than  in  higher  latitudes.  Hirsch  states  that  whooping-cough  is 
independent  of  physical,  social,  and  racial  conditions.  It  is  pre-eminently 
an  epidemic  disease.  Outbreaks  of  whooping-cough  have  so  often  closely 
coincided  with  the  prevalence  of  measles,  as  to  suggest  some  causal  relation- 
ship between  the  two  maladies,  which  are  said  to  hunt  in  couples.  Such 
a  relationship,  however,  has  not  yet  been  proved. 

Girls  are  more  prone  to  take  whooping-cough  than  boys,  and  they  also 
die  of  it  in  relatively  greater  numbers. 

Although  especially  a  disease  of  childhood,  it  is  by  no  means  unknown 
in  adults  up  to  40  or  50.  Hilton  Fagge  reminds  us  that  an  eminent 
London  physician  suffered  from  an  attack  of  whooping-cough  when  more 
than  65  years  of  age.  Heberden  met  with  one  case  in  a  woman  set.  70, 
and  another  in  a  man  set.  80. 

The  bacteriology  of  whooping-cough  is  still  obscure.  Burger  says  that 
elliptical  cocci  are  constantly  present  in  the  expectoration  of  persons 
suffering  from  the  disease.  They  are  said  to  be  easily  brought  into  view 
by  staining  with  iuschin  or  methyl- violet.  Afanassiev  isolated  from  the 
sputum  of  whooping-cough  a  short,  thick  bacillus,  pure  cultures  of  which 
produced,  after  inoculation  in  dogs  and  rabbits,  symptoms  resembling 
whooping-cough  and  broncho-pneumonia.  Koplik  found  a  very  minute 
bacillus  with  rounded  ends  in  thirteen  out  of  sixteen  cases  of  whooping- 
cough.  O.  Zusch  described  a  bacillus  which  he  found  in  the  sputum  of 
twenty-five  children  with  whooping-cough.  Be  this  as  it  may,  infectious 
particles  are  certainly  expelled  with  the  cough  from  an  early  stage,  and  if 
these  should  reach  the  air  passages  of  the  susceptible,  the  disease  is  com- 
municated to  them.  Fomites  also  play  an  important  part  in  the  diffusion 
of  the  malady.  Hilton  Fagge  adduces  a  striking  instance  in  which  a  boy 
in  the  early  stage  sneezed  and  coughed  on  a  lady's  dress  while  climbing 
upon  her  knee.  Early  next  morning  her  own  little  daughter  was  found 
playing  over  the  same  dress,  which  had  been  laid  upon  an  ottoman,  with 
the  result  that  exactly  thirteen  days  afterwards  this  girl  took  ill  and  after- 
wards gave  whooping-cough  to  two  other  children.  The  complaint  has  not 
been  directly  produced  by  inoculation. 

Morbid  anatomy  and  pathology. — Even  assuming  that  the 
specific  virus  or  poison  of  whooping-cough  has  not  yet  been  identified  and 
isolated,  the  extreme  contagiousness  of  the  disease,  and  the  marked 
immunity  which  one  attack  bestows  upon  its  victims,  leave  us  no  option 
but  to  assign  it  a  place  among  the  so-called  zymotic  or  infective  diseases. 
Numerous  theories  have  been  advanced  to  explain  the  phenomena  of 
whooping-cough.  A  specific  catarrh  with  hypersesthesia  is  admitted  by 
all.  "  One  can  easily  imagine,"  says  Hilton  Fagge,  "  that  the  poison  of 
this  disease,  having  originally  entered  the  air  passages  from  without,  and 
having  set  up  a  catarrh  there,  is  during  the  prodromal  stage  conveyed  to 
some  part  of  the  central  nervous  system,  and  there  sets  up  the  peculiar 


PERTUSSIS —  WHOOPING-  CO  UGH.  183 

spasmodic  cough."  The  vagus  nerve  bears  the  brunt  of  the  poisoning; 
hence  the  weak,  quick  pulse,  the  disturbances  of  respiration  and  of 
digestion,  the  tendency  to  hyperemia  of  the  lungs,  the  epigastric  tender- 
ness, and  the  spasmodic  cough.  This  last-named  and  highly  characteristic 
symptom  may  also  be  caused  by  a  reflex  peripheral  excitement  of  the 
vagus  due  to  the  swelling  of  the  bronchial  glands  in  the  spasmodic  stage  of 
the  disease.  Several  causes  probably  co-operate  in  producing  the  dissem- 
inated pneumonia  of  whooping-cough.  Extension  of  a  bronchiolitis  into 
the  adjoining  pulmonary  lobules,  vesicular  hyperemia  from  rarefaction  of 
air  in,  and  collapse  of,  the  alveoli  during  the  forced  and  repeated  expira- 
tions, each  plays  its  role ;  but,  above  all,  we  must  regard  the  lesion  in  the 
lung  as  a  true  inhalation  pneumonia. 

Symptomatology. — We  may  consider  the  disease  as  it  passes 
through  its  periods  of  latency,  of  invasion,  of  spasm,  and  of  convalescence. 

Incubation. — This  is  variable  in  length.  Four  days  are  assigned  as  its 
shortest,  a  fortnight  as  its  longest,  limit.  Perhaps  ten  days  may  be  regarded 
as  its  average  duration — the  same  as  measles.  Towards  the  close  of  this 
stage,  slight  catarrhal  and  feverish  symptoms  may  present  themselves. 

Invasion. — The  invasion  stage,  or  premonitory,  prodromal,  or  catarrhal 
stage,  commonly  lasts  a  week.  It  may  be  entirely  absent,  or  it  may  con- 
stitute the  whole  of  the  attack,  the  patient  recovering  in  two,  four,  or  five 
weeks,  without  more  distinctive  symptoms. 

The  onset  of  whooping-cough  is  gradual  and  insidious.  The  child  is 
out  of  sorts,  fretful,  peevish ;  looks  pale  and  ill,  and  does  not  eat.  Tem- 
perature rises  at  night,  sometimes  considerably;  sneezing  and  a  harsh 
brassy  cough  set  in  towards  evening,  or  on  slight  exertion,  while  the 
morning  state  is  more  satisfactory.  The  glanduke  concatenate  in  the 
neck  enlarge.  Examination  of  the  chest  reveals  bronchial,  dry,  and  moist 
sounds  (rhonchi  and  rales),  without  dulness  on  percussion.  The  cough 
becomes  worse  and  worse,  more  and  more  explosive  in  character ;  its 
paroxysms  are  more  and  more  prolonged.  At  the  same  time,  it  does  not 
"  soften,"  nor  is  secretion  expelled  or  swallowed,  as  in  ordinary  bronchial 
catarrh. 

Spasm. — When  the  catarrhal  stage  has  lasted  for  a  week  or  ten  days, 
the  cough,  instead  of  subsiding,  becomes,  except  in  mild  cases,  more  and 
more  convulsive  in  character,  shows  a  disposition  to  occur  in  fits  or 
paroxysms,  and  is  often  attended,  or  followed  by,  vomiting.  Whenever 
a  fit  of  coughing  is  imminent,  the  patient's  face  is  seen  to  redden  as  he 
makes  a  vain  effort  to  stifle  or  "  smother "  the  cough,  the  only  effect  of 
which,  however,  is  to  hasten  and  intensify  the  attack.  A  quick  succession 
of  ten  to  twenty  sharp,  short,  noisy,  barking  coughs  of  ever-increasing 
violence  and  boisterousness,  culminates  in  a  brief  spell  of  apncea.  This  is, 
in  turn,  rapidly  followed  by  a  loud,  shrill,  and  deep  crowing  inspiration — 
the  so-called  "whoop,"  from  which  the  disease  obtains  its  name.  Just 
before  this  forced  and  stridulous  inspiration  happens,  the  appearance  of  the 
patient  betokens  asphyxia ;  the  face  is  livid,  congested,  and  swollen,  the 
veins  stand  out  like  cords,  the  eyes  are  bloodshot,  the  eyeballs  seem  about 
to  start  from  their  sockets,  and  now  and  then  the  nose  begins  to  bleed. 

Scarcely  has  such  a  fit  of  coughing  passed  off,  when  another  like 
seizure  begins.  This  may  be  equally  severe,  or  shorter  in  duration,  or  less 
intense.  And  so  the  attack  goes  on,  until,  after  several  fits  of  explosive 
coughing,  some  more  or  less  white,  glairy,  stringy  mucus  is  discharged  by 
expectoration  or  vomiting,  or  by  both  combined.     Paroxysms  like  that 


1 84  GENERAL  DISEASES. 

described  may  return  only  five  or  six  times  in  the  twenty-four  hours, 
or  they  may  mount  up  to  as  many  as  sixty  to  eighty.  They  are  especially 
liable  to  take  place  at  night.  They  cause  great  distress,  and  their 
approach  is  regarded  by  young  children  with  terror.  A  child  playing 
with  his  toys  will  suddenly  stop  in  his  play,  and  run  to  a  bystander 
for  help  when  he  feels  the  attack  coming  on.  Older  patients  describe  a 
feeling  of  constriction  in  the  throat,  or  a  tickling  in  the  larynx ;  infants 
look  frightened,  and  become  intensely  restless  as  the  seizure  threatens. 

At  all  times  irregular  in  whooping-cough,  the  temperature  in  this 
spasmodic  stage  varies.  Usually  it  is  normal,  or  nearly  so,  while  the 
pulse  remains  rapid.  But  if  the  spasms,  through  their  frequency  and 
intensity,  induce  disseminated  broncho-pneumonia,  or  catarrhal  pneumonia, 
considerable  fever  may  develop,  and  the  temperature  may  rise  to  104°  F., 
or  even  higher. 

When  the  child  is  very  young,  and  the  fits  of  coughing  are  frequent 
and  severe,  grave  symptoms  develop.  These  are — duskiness  of  the  face, 
cyanosis,  oedema  of  the  face  and  neck,  bloodshot  eyes,  nose-bleeding, 
blood-stained  expectoration,  deafness  from  rupture  of  the  membrana 
tympani,  escape  of  blood  from  the  ear  or  ears,  squinting,  temporary  loss  of 
sight  during  the  fit,  transient  albuminuria,  spasmodic  movements  of  the 
face  muscles,  and  general  convulsions,  ending  in  coma  and  death. 

Exhaustion  for  a  while  follows  a  paroxysm,  or  headache  is  complained 
of ;  the  child,  however,  soon  regains  its  wonted  cheerfulness,  and  asks  for 
food,  especially  if  he  has  vomited. 

The  complications  which  may  accompany  the  spasmodic  stage  are: 
Bronchitis,  of  varying  degrees  of  intensity  and  extent ;  pneumonia  of  the 
catarrhal  type,  and  lobular  in  distribution ;  collapse  of  the  lung ;  pleurisy, 
which  may  end  in  empyema  or  pyothorax ;  pulmonary  emphysema,  rarely 
general  emphysema  or  pneumothorax.  Samuel  West  has  recorded  a 
case  of  right  hemiplegia  with  aphasia  and  athetosis,  probably  due  to 
cerebral  haemorrhage  during  a  paroxysm  in  whooping-cough.  Hilton  Fagge 
mentions  ascending  paralysis  as  a  rare  sequela,  and  perhaps  depending  on 
peripheral  neuritis.  In  this  stage,  also,  probably  as  the  result  of  mechan- 
ical chafing  against  the  teeth,  or  even  the  gum,  in  a  toothless  infant,  one 
or  more  shallow  sore  ulcers  form  upon  the  frsenum  linguae,  or  alongside  it 
on  the  under  surface  of  the  tongue.  These  were  first  described  by 
Bouchard  and  other  continental  writers ;  but,  in  this  country,  attention 
was  first  drawn  to  them  by  Thomas  Morton.  The  sublingual  ulcers  were 
met  with  by  Morton  in  about  40  per  cent,  of  his  cases,  generally  between 
the  third  and  fifth  week,  so  that  their  recognition  aids  the  diagnosis. 

Decline  and  convalescence. — After  a  fortnight  or  so  of  violent  fits  of 
coughing,  the  intensity  of  the  attacks  lessens,  the  intervals  between 
successive  paroxysms  lengthen,  the  secretion  of  the  bronchial  mucous 
membrane  becomes  looser,  and  is  more  easily  got  rid  of,  and  the  patient 
shows  evidence  of  returning  health  and  strength.  The  least  indiscretion 
or  want  of  care  may  in  this  stage  cause  a  relapse,  or  induce  some 
pulmonary  complication.  In  favourable  cases,  convalescence  is  completed 
within  six  weeks  from  the  onset  of  the  attack.  In  other  cases,  the  disease 
may  last  two  months,  or  longer,  and  convalescence  may  be  very  protracted, 
particularly  in  winter.  Caseating  bronchial  glands  and  deposits  in  the 
air  vesicles  of  the  lungs  again  may  pave  the  way  for  tuberculous  infection 
and  resulting  pulmonary  phthisis.  Tuberculous  meningitis  and  acute 
tuberculosis  are  rapidly  fatal  sequelae. 


PER  TUSSIS —  WHO  OPING-  CO  UGH.  1 8  5 

Diagnosis. — In  the  early  or  prodromal  stage,  whooping-cough  may 
be  confounded  with  a  simple  catarrh,  or  with  epidemic  influenza.  In  all 
cases,  attention  should  be  paid  to  the  prevailing  epidemic.  Influenza 
attacks  persons  at  all  ages,  comes  on  suddenly,  with  rheumatoid  pains, 
high  temperature,  and  often  nervous  or  gastric  symptoms.  Children 
affected  with  influenza  do  not  whoop.  Simple  catarrh  and  bronchitis  are 
especially  diseases  of  winter.  When  suffering  from  them,  children  do  not, 
as  a  rule,  expectorate  or  vomit,  and  these  affections  are  directly  attribut- 
able to  exposure  to  cold  or  a  wetting,  while  they  come  on  suddenly,  and 
are  early  attended  by  hoarseness  from  laryngitis. 

Hay  fever  or  summer  catarrh  occurs  in  early  summer,  when  the  air  is 
laden  with  the  pollen  of  grasses  and  of  various  shrubs  and  trees.  The 
malady  affects  adults  rather  than  children,  and  only  a  certain  number  of 
individuals  are  prone  to  it.  Hysteria  is  sometimes  accompanied  by  a 
spasmodic,  hard,  brassy  cough,  which  is,  however,  incessant,  and  unattended 
by  the  characteristic  whoop.  Hysteria  affects  girls  and  young  women ;  is 
independent  of  season,  and  is  infectious  only  by  imitation — it  is  a  mimetic 
neurosis. 

Prognosis. — Whooping-cough  is  a  dangerous  malady  in  infancy,  in 
badly-housed  and  badly-nourished  children,  and  in  those  who  are  rickety. 
It  is  naturally  more  fatal  in  winter  and  spring  than  in  summer  and 
autumn.  According  to  the  United  States  Census  Eeports,  it  is  more 
than  twice  as  fatal  in  the  negro  race  than  in  others.  A  paroxysm 
seldom  kills,  but  it  may  cause  death  in  a  very  young  child  through 
complete  closure  of  the  glottis,  perhaps  from  syncope,  or  through  the 
rupture  of  an  intracranial  blood  vessel.  Fatal  coma  may  supervene 
where  the  paroxysms  are  frequent  and  violent.  Convulsions  are  most 
dangerous  in  any  stage  of  the  disease.  It  is,  however,  to  the  concurrent 
bronchitis  and  pneumonia  of  whooping-cough  that  the  majority  of  the 
fatal  cases  are  due.  The  accidents  of  pulmonary  emphysema  and  collapse 
often  end  in  recovery,  probably  because  of  the  youth  of  the  patients.  On 
the  other  hand,  caseation  of  the  deposits  in  the  pulmonary  alveoli,  or  of 
the  unresolved  bronchial  and  mediastinal  glands,  supplies  a  fertile  soil  for 
the  Bacillus  tuberculosis.  Lastly,  convalescence  is  often  delayed  by  fresh 
catarrhal  attacks  in  cold  weather,  or  by  continued  loss  of  appetite. 

In  England  and  Wales  the  deaths  from  all  causes  in  the  ten  years, 
1881-90,  gave  a  death-rate  of  19-08  per  1000  of  the  population  annually. 
The  corresponding  figure  for  whooping-cough  was  045  per  1000.  The 
fatal  cases  of  this  disease  at  all  ages  amounted  to  123,597  in  the  decade. 
Included  among  these  deaths  were  119,200  of  children  under  5  years  of 
age.  Under  1  year,  53,407  died;  between  1  and  2  years,  37,774 ;  between 
2  and  3  years,  15,299 ;  between  3  and  4  years,  8,292 ;  between  4  and  5 
years,  4,428. 

Treatment. — So  far  no  specific  for  whooping-cough  has  been  dis- 
covered. Fresh  air  is  the  nearest  approach  to  a  specific  which  we  at 
present  possess  ;  but  in  using  it  we  must  not  unduly  expose  our  patient — 
a  child,  sensitive  to  cold  in  more  ways  than  one,  for  the  exposure  may 
bring  on  a  paroxysm  or,  still  worse,  induce  an  attack  of  bronchitis.  In  fine 
weather,  however,  open-air  exercise  may  be  allowed.  At  other  times  a 
warm  equable  temperature  and  a  large  airy  room  are  essential.  Towards 
convalescence,  change  of  air,  particularly  to  or  near  the  seaside,  hastens 
recovery.  The  diet  should  be  light  and  nutritious,  consisting  largely  of 
milk,  animal  broths,  and  egg  puddings.      The  meals  should  be  given  at 


1 86  GENERAL  DISEASES. 

shorter  intervals  than  in  health,  and.  if  possible,  after  the  several  par- 
oxysms of  cough,  so  as  to  ensure  that  they  will  not  be  ejected  by  vomiting. 
All  excitement  must  be  avoided,  for  undue  talking,  crying,  or  laughing  may 
bring  on  a  fit  of  coughing. 

The  air  of  the  room  occupied  by  the  sick  child  or  children  may,  with 
benefit,  be  impregnated  with  a  disinfectant,  such  as  turpentine,  carbolic 
acid,  creosote,  guaiacol,  sulphurous  acid  gas — the  last,  in  particular,  appears 
to  possess  direct  curative  properties,  and  the  patients  soon  come  to  bear 
quite  a  concentrated  atmosphere  of  it.  Thiocamf  may  be  substituted  for 
sulphurous  acid.  It  is  a  liquid  combination  of  sulphur  dioxide,  camphor, 
and  various  volatile  aromatic  bodies. 

As  regards  the  internal  administration  of  drugs,  little  need  be  said.  A 
sip  of  cold  water  now  and  again  often  allays  cough  and  is  grateful  to  the 
sufferer.  In  the  catarrhal  stage,  a  simple  mixture  of  ipecacuanha  wine 
with  solution  of  citrate  or  acetate  of  ammonium,  glycerin,  and  water, gives 
relief.  Cherry  laurel  water,  or  minim  doses  of  dilute  hydrocyanic  acid, 
may  be  prescribed  in  combination  with  one  or  more  of  the  bromides.  The 
chest  should  be  gently  rubbed  with  a  liniment  of  chloroform  and  camphor  of 
moderate  strength,  and  afterwards  poulticed  with  linseed  meal  or  wrapped 
in  wadding  under  oiled  silk,  or  covered  with  Gamgee  tissue. 

In  the  spasmodic  stage,  in  addition  to  the  foregoing,  we  may  order 
chloral  hydrate  and  quinine — 1  gr.  of  the  latter  per  diem  in  powder  for 
each  year  of  age,  continued  for  two  or  three  days  only.     Alum  is  recom- 
mended (1  to  5  grs.  every  four  hours)  in  this  and  the  final  stage,  or  the 
addition  of  compound  tincture  of  camphor  to  the  ipecacuanha  wine,  one 
part  to  two  for  young  children,  two  parts  to  one  in  chloroform  water  in 
adolescence.    Inhalations  of  nitrite  of  amyl  are  of  use  in  spasm.    Belladonna 
is  often  given  in  combination  with  carbonate  of  potassium — 10  minims  of 
the  tincture  thrice  daily  is   the  dose  for  a  child  of  3  years.      Hydro- 
chlorate  of  cocaine  (^  gr.  to  \  gr.  thrice  daily)  is  favourably  spoken  of  by 
Goodall  and  Washbourn,  while  several  writers  have  testified  to  the  great 
utility  of  bromoform  in  controlling  the  paroxysms  and  relieving  vomiting. 
The  capsules  of  bromoform  contain  a  half  or  one  minim  dissolved  in  oil. 
Bromoform  may  also  be  dropped  upon  a  lump  of  sugar  or  into  water,  or  it 
may  be  given  in  combination  with  alcohol,  as  suggested  by  Carpenter — 
R 

Bromoformi         .....        rn,xlviij 

Alcohol       ......        Jss 

Tract,  cardarnorai  comp.        .  .  .ad  ^iij 

M. 
Signa. — Shake  the  bottle.     A  fluid  drachm  three  times  a  day  in  water. 

J.  W.  MOOEE. 


MUMPS— EPIDEMIC   PAEOTITIS. 

Syn.,  Scots.,  The  Branhs ;  Lat.,  Angina  maxillaris  vel  parotidea,  Cynanche 
parotidea ;  Er.,  Oreillons,  Ourles  ;  Ger.,  Ziegewpeter,  Bauerwetzel. 

An  acute,  specific,  and  infectious  febrile  disease,  characterised  by  in- 
flammation of  the  salivary  glands — especially  the  parotid  gland — often 
assuming  an  epidemic  form,  occurring  as  a  rule  once  only  in  a  lifetime, 
and    supposed   to   be    propagated   by   means   of   the   breath    and    saliva. 


MUMPS — EPIDEMIC  PAROTITIS.  187 

The  testes  in  the  male,  the  external  genitals  and  mammae  in  the  female,  are 
sometimes  involved  in  the  specific  inflammation  of  mumps.  The  ovaries 
are  very  rarely,  if  ever,  engaged.  These  metastases  usually  take  place  when 
the  parotid  symptoms  are  declining.  The  disease  is  in  general  not  dangerous 
to  life ;  but  if  suppuration  occurs,  the  mastoid  cells  may  become  implicated, 
leading  to  meningitis  or  to  pyaemia. 

History. — Hirsch  tells  us  that  epidemics  of  inflammation  of  the 
parotid  gland  were  long  ago  described  in  a  masterly  fashion  by  Hippocrates, 
who  also  pointed  out  the  fact,  observed  by  himself,  that  swelling  of  the 
testicle  may  occur  in  the  course  of  the  disease.  Mumps  is  found  in  all 
countries  and  in  all  climates,  no  part  of  the  habitable  globe  being  exempt 
from  this  strange  malady.  It  occurs  either  in  circumscribed  outbreaks  in 
schools  or  barracks,  or  in  widespread  epidemics.  Many  records  exist  of  the 
prevalence  of  mumps  among  troops  in  garrison  or  in  the  field,  and  it 
occasionally  breaks  out  on  board  ships  of  war.  In  the  American  War  of 
1862-65,  mumps  occurred  to  a  notable  extent,  particularly  in  the  first 
year  of  the  war,  when  forty  cases  were  reported  among  every  1000  men. 
Of  48,128  cases  reported  altogether,  seventy-two  died. 

Etiology. — No  doubt  exists  as  to  the  contagiousness  of  mumps.  It 
is  certainly  an  infective  disease.  Its  exciting  cause  would  seem  to  be  a 
micro-organism  discovered  by  Michaelis.  In  1897,  Bein  described  this 
micro-organism  as  a  streptococcus,  very  similar  in  its  shape  and  in  its 
attitude  in  the  cells  to  the  gonococcus  and  to  the  meningococcus.  It  grew 
in  ordinary  agar,  peptone  bouillon,  and  ascitic  fluid.  It  curdled  milk  and 
liquefied  gelatin.  Its  movements  were  peculiar.  Fresh  cultures  would 
kill  mice.  It  had  been  found  in  the  secretion  from  Steno's  duct,  in  the 
contents  of  parotid  abscesses,  and  once  in  the  blood. 

The  prevalence  of  the  malady  is  favoured  by  cold  and  wet.  Its 
epidemics  generally  arise  in  winter  after  spells  of  cold,  wet  weather,  and  its 
victims  are  principally  those  who  have  been  most  exposed  to  such  weather. 
Children,  other  than  infants,  and  soldiers  show  a  singular  predisposition  to 
mumps.  It  is,  however,  met  with  at  all  ages,  and  some  years  ago  I 
observed  an  instance  in  which  an  adult  maid-servant  infected  a  family 
of  young  children,  from  whom  their  aunt  and  grandmother  subsequently 
took  the  disease.  Boys  are  more  prone  to  catch  the  disease  than  girls. 
Mumps  has  not  infrequently  been  epidemic  at  the  same  time  as  certain 
eruptive  fevers,  particularly  measles  and  scarlatina.  This  appears,  how- 
ever, to  be  a  mere  coincidence.  The  infection  clings  to  a  patient  for  two 
or  three  weeks  after  the  parotid  gland  swells. 

Morbid  anatomy  and  pathology. — As  regards  the  local  lesion, 
the  inflammation  would  appear  to  fall  much  more  heavily  on  the  connective 
tissue  stroma  of  the  parotid  and  salivary  glands  than  on  the  acini  of  these 
glands  themselves.  It  involves  also  the  connective  tissue  elements  which 
surround  the  glands ;  in  a  word,  we  have  to  deal  with  an  interstitial  rather 
than  a  parenchymatous  inflammation.  Cellulitis  occurs  and  may  spread 
to  neighbouring  lymph  glands. 

Symptomatology. — The  stage  of  incubation  lasts  for  one  week  to 
three  weeks.  It  is  generally  about  a  fortnight.  The  initial  or  prodromal 
symptoms  are — a  feeling  of  fatigue,  chill  in  ess,  gastric  derangement  and 
vomiting,  and  restlessness  at  night.  Then  the  temperature  rises  to  100° 
or  101°  in  most  cases,  to  103°  or  104°  in  others.  Aching  pain  and  swelling 
soon  set  in  at  one  side  of  the  face,  involving  the  parotid  and  submaxillary 
glands.      The  pain  sometimes  resembles  toothache,  at  other  times  it  is 


1 88  GENERAL  DISEASES. 

absent,  or  it  consists  in  a  feeling  of  stiffness  and  discomfort  about  the  jaw, 
with  inability  to  open  the  mouth  wide  or  to  chew  solid  food.  Yawn- 
ing gives  great  pain,  and  even  speaking  causes  distress.  A  swelling  quickly 
appears  at  this  time  under  one  ear.  It  spreads  backward  under  the  sterno- 
mastoid  muscle,  forward  to  the  angle  of  the  jaw,  and  downward  along  the 
side  of  the  neck.  The  tumour  displaces  the  lobe  of  the  ear.  It  feels 
elastic,  is  slightly  softer  in  the  centre,  but  does  not  pit  on  pressure.  Over 
it,  the  skin  is  tense,  shining,  and  swollen,  pale  in  colour  and  waxy-looking, 
but  occasionally  showing  a  red  blush.  Salivation  may  accompany  the 
swelling,  but  frequently  the  secretion  of  saliva  is  unaltered  in  quantity  or 
quality,  sometimes  it  is  diminished.  There  may  be  hardness  of  hearing  on 
the  affected  side.  Tinnitus  aurium  also  occurs,  or  complaint  may  be  made 
of  shooting  pains  in  the  ear  or  ears.  In  some  cases  the  swelling  is  limited 
to  one  side,  in  others  both  sides  are  attacked  together.  Most  usually,  as 
the  swelling  of  one  side  begins  to  go  down,  the  other  side  becomes  affected. 
Pyrexia  ceases  about  the  fourth  day.  The  tonsils  and  neighbouring  parts 
may  swell  in  mumps.     The  breath  has  often  a  heavy,  foetid  smell. 

The  tumefaction  subsides  as  quickly  as  it  developed,  so  that  absorption 
is  completed  in  three  or  four  days.  The  whole  duration  of  the  attack 
varies  from  a  week  or  ten  days  to  a  fortnight. 

The  skin  occasionally  peels  over  the  affected  parts,  especially  when  they 
have  been  poulticed  or  fomented. 

Complications  are  rare.  The  most  common  is  the  so-called  "  meta- 
static "  orchitis  of  boys  and  young  men.  This  comes  on  as  the  face  troubles 
decline.  The  right  testicle  is  credited  with  being  most  frequently  affected. 
Temperature  rises  again,  so  that  high  fever  and  delirium  may  appear. 
Collapse  occurred  in  a  man  set.  35  under  Trousseau's  care  ;  but  yielded  to 
treatment,  and  especially  to  the  development  of  a  metastatic  orchitis.  In 
another  case  observed  by  him,  that  of  a  lad  set.  17,  the  typhoid  or 
ataxic  state  developed,  but  gave  way  on  the  supervention  of  swelling  of  the 
scrotum  and  one  testicle.  Orchitis  in  mumps  lasts  from  three  to  six  days, 
and  then  quickly  subsides.  It  may,  however,  lead  to  permanent  atrophy 
of  the  testicle,  or  epididymitis  may  develop.  Morton  long  ago  described 
cases  of  this  kind  under  the  expressive  term,  Febris  testicularis. 

Acute  otitis  may  rarely  occur.  Also,  very  rarely,  ophthalmia.  Hilton 
Fagge  further  mentions  acute  bronchitis,  bubo,  and  urethritis  as  occasional 
complications  of  mumps.  Zinn  reports  a  case  of  endocarditis  in  a  boy 
get.  13.  To  these  should  be  added  mastitis  and  oedema  of  the  vulva  in 
girls. 

Diagnosis. — Mumps  is  easily  recognised.  From  faceache  it  is  dis- 
tinguished by  its  sharp  fever  and  the  development  of  the  parotid  swelling. 
Occasionally  a  secondary  or  metastatic  parotitis  occurs  in  the  course 
of  severe  enteric  fever  or  other  acute  infective  disease,  and  in  1887, 
Stephen  Paget  drew  attention  to  the  occurrence  of  suppurative  parotitis  in 
abdominal  and  pelvic  diseases.  In  1892,  the  same  surgeon  reported  a  case 
of  abdominal  section  followed  by  parotitis.  But,  in  all  these,  early  suppura- 
tion takes  place  in  the  inflamed  parotid  gland.  The  cervical  swelling  in 
diphtheria  may  be  mistaken  for  mumps ;  but  examination  of  the  mouth 
and  throat  should  solve  any  difficulty  in  diagnosis. 

Prognosis. — Mumps  is  a  comparatively  trivial  disease,  in  the  absence 
of  any  constitutional  delicacy  or  tuberculisation.  In  rare  instances,  secondary 
meningitis  has  destroyed  life,  after  suppuration  had  occurred,  involving  the 
mastoid  cells.     This  train  of  events  was  demonstrated  during  the  course  of 


INFLUENZA — EPIDEMIC  CATARRHAL  FEVER.  189 

the  American  War  of  1862-65.     It  should  not  be  forgotten  that  atrophy  of 
the  testicle  may  be  a  sequela  in  a  case  of  metastatic  orchitis. 

Treatment. — Rest  in  bed  during  the  febrile  stage  is  judicious  at  all 
times,  it  is  essential  in  winter.  The  patient  should  in  any  case  remain  in 
a  warm,  equable  atmosphere  until  the  parotid  swelling  has  entirely  sub- 
sided. Metastasis  is  apt  to  occur  after  exposure  to  cold  and  wet  or  from 
over-fatigue  in  convalescence. 

As  the  patient  cannot  masticate,  nourishing  broths,  jellies,  milk  pre- 
parations, and  whipped-up  eggs  should  be  ordered.  Ice  is  very  refreshing 
and  useful.  Attention  should  be  paid  to  the  state  of  the  bowels,  and 
rest  at  night  should  be  secured  by  Dover's  powder,  or  by  chloral  and 
bromide  draughts,  or  some  other  means.  The  simplest  application  to  the 
swelling  is  a  pad  of  Gam  gee  tissue  or  French  wadding  under  oiled  silk. 
Warm  fomentations  also  give  relief — infusion  of  chamomile  or  decoction  of 
poppies  may  be  used  for  the  purpose.  Should  suppuration  threaten,  free 
poulticing  will  be  of  service.  Tepid  sponging  all  over  the  body,  or  even  a 
warm  bath,  is  grateful  and  soothing.  The  bath  should  always  be  resorted 
to  when  metastasis  is  suspected.  In  convalescence,  tonics  like  iron, 
quinine,  arsenic,  strychnine,  and  cod-liver  oil  are  indicated. 

J.  W.  MOOKE. 


INFLUENZA— EPIDEMIC  CATARRHAL  FEVER 

Syn.,  Lat.,  Catarrhus  epidemicus ;  Fr.,  La  Grippe ;  Ger.,  Epidemischer 

Schnupfenfieber. 

Influenza  is  a  very  acute,  specific,  infectious  febrile  disease.  Its  virus 
or  contagium,  when  once  introduced  into  the  body,  presumably  by  in- 
halation, acts  primarily  and  quickly  on  the  nervous  system,  producing 
the  symptoms  of  an  acute  pyrexia,  with  remarkably  rapid  pulse.  The 
malady  is  undoubtedly  contagious,  but  its  incubation  stage  is  singularly 
short.  Its  outbreaks  are  so  sudden  and  often  so  widespread,  affecting 
multitudes  at  one  and  the  same  moment,  both  by  sea  and  land,  as  to 
suggest  a  miasmatic  origin.  Viewed  in  this  light,  the  micro-organisms 
concerned  in  the  production  of  the  disease  may  possibly  undergo  multipli- 
cation and  development  in  the  atmosphere  itself,  so  causing  the  pandemic 
rather  than  epidemic  prevalence  of  the  malady.  Very  young  children 
seem  to  enjoy  a  certain  immunity  from  influenza,  or  to  have  it  in  a  mild 
form — as  an  ephemeral  fever,  followed  by  profuse  sweating,  and,  after  a  few 
days,  a  tendency  to  slight  catarrh. 

Influenza,  while  infrequently  directly  fatal,  causes  an  indirect  loss  of  life 
which  is  appalling,  chiefly  through  complications  affecting  the  respiratory 
and,  in  advanced  life,  the  circulatory  systems.  It  has  been  said  that 
influenza,  while  relatively  less  fatal,  is  absolutely  more  fatal,  than  cholera. 

Influenza  is  a  perilous  complication  of  pulmonary  consumption.  It 
seems  to  have  the  property  of  picking  out  the  weak  point  in  an  individual's 
constitution.  It  shows  a  marked  tendency  to  relapse,  and  to  this  is  largely 
due  the  indirect  fatality  of  the  malady.  The  febrile  movement  in  even 
uncomplicated  influenza  is  polytypical  or  atypical — that  is,  it  presents 
many  varieties  and  is  not  characteristic.  It  lasts  from  two  to  six  or 
seven  days.     Fever  is  occasionally  entirely  absent.     Unlike  most  of  the 


i9o  GENERAL  DISEASES. 

other  acute  specific  diseases,  influenza  confers  no  immunity  against  future 
attacks. 

History. — The  earliest  authentic  notices  of  influenza  date  from  a.d. 
1173,  in  December  of  which  year  there  was  an  epidemic  in  Italy,  Germany, 
and  England.  Numerous  outbreaks  subsequently  took  place  either  as 
pandemics  or  as  circumscribed  epidemics,  from  time  to  time  down  to  1847, 
in  the  late  autumn  and  winter  of  which  year  the  disease  became  generally 
diffused  over  the  Eastern  Hemisphere.  Epidemics  occurred  still  later  in 
1850-51, 1855, 1857-58,  and  1874-75,  but  none  of  these  visitations  pro- 
duced a  deep  impression  on  the  medical  mind,  and  the  British  Isles  in 
particular  almost  escaped  them.  It  thus  happened  that,  when  the  so-called 
Eussian  influenza  swept  westward  across  Europe,  towards  the  close  of 
the  year  1889,  the  malady  presented  itself  as  practically  a  new  and  unknown 
disease  to  the  vast  majority  of  the  physicians  who  were  called  upon  to 
treat  it,  and  whose  experience  did  not  go  back  to  the  memorable  outbreak 
of  1847.  Since  1889,  successive  waves  of  influenza  have  surged  across 
both  the  Eastern  and  Western  Hemispheres,  and  now  (1899)  the  terms 
influenza  and  Grippe  are  as  familiar  as  household  words  in  all  parts  of 
the  world. 

Etiology. — In  1892,  a  bacillus  was  discovered  by  Pfeiffer,  and 
independently  by  Canon,  which  is  believed  to  be  the  specific  cause  of 
influenza.  Pfeiffer  detected  the  bacillus  in  the  purulent  bronchial  secre- 
tion, Canon  in  the  blood,  of  influenza  patients.  Its  presence  in  the  blood 
is  not  established  by  the  experience  of  observers  other  than  Canon. 

The  Bacillus  influenza;  is  very  minute,  about  0  5  /u,  in  length  and  0*2  /u 
in  diameter — that  is,  half  as  long  only  as  Koch's  bacillus  of  mouse-septic- 
semia,  but  the  same  thickness  as  that  micro-organism.  It  is  aerobic,  non- 
motile.  Spore  formation  has  not  been  observed.  It  is  solitary  or  united  in 
twos,  resembling  diplococci,  or  in  chains  of  three  or  four  elements.  When 
cultivated,  these  bacilli  grow  well  in  broth  and  on  the  surface  of  glycerin 
agar  at  37°  C.  (980,6  F.).  They  do  not  thrive  at  temperatures  below  28°  C. 
(82° -4  F.)  (Klein).  Kitasato  considers  that  they  are  a  definite  species, 
not  occurring  in  any  disease  except  influenza.  The  bacilli  are  quickly 
destroyed  by  desiccation.  The  thermal  death  point  is  60°  C.  (140°  F.)  with 
five  minutes  exposure. 

Pfeiffer  infers  that  this  bacillus  is  the  specific  cause  of  influenza  in  man, 
because  it  was  found  in  all  uncomplicated  cases  of  influenza  examined, 
in  the  characteristic  purulent  bronchial  secretion  ;  often  in  the  protoplasm 
of  the  pus  corpuscles,  and  (in  fatal  cases)  in  the  peribronchial  tissue  and 
on  the  surface  of  the  pleura ;  it  was  found  only  in  cases  of  influenza ;  the 
presence  of  the  bacillus  corresponded  with  the  course  of  the  disease,  and  it 
disappeared  with  the  cessation  of  the  purulent  bronchial  secretion. 

Having  regard  to  the  clinical  history  of  influenza,  it  is  hard  to  believe 
that  the  disease  is  only  contagious  and  not  also  air-borne.  To  use  an 
expression  familiar  to  the  physicians  of  the  sixteenth  and  seventeenth 
centuries,  the  virus  of  influenza  would  seem  to  cause  a  fouling  of  the  air 
or  miasma,  from  which  its  pandemic  outbreaks  presumably  take  their  rise. 

In  a  word,  Pfeiffer's  B.  influenza?  is  perhaps  a  facultative  parasite 
— that  is,  it  can  exist  independently  of  a  living  host  as  a  saprophyte, 
although  it  usually  plays  the  role  of  a  true  parasite. 

Of  course  it  is  not  denied  that  the  morbific  agent  or  virus  is  capable 
of  clinging  to  the  human  body,  or  to  clothes  or  luggage  or  letters,  so  as  to 
be  conveyed  by  them  from  place  to  place.      "  But,"  says  Hilton  Eagge, 


INFLUENZA — EPIDEMIC  CATARRHAL  FEVER.  19 1 

"its  subsequent  growth  and  development  is  doubtless  altogether  inde- 
pendent of  this  kind  of  assistance."  The  prevalence  of  the  disease  is 
uncontrolled  by  season  or  weather. 

Morbid  anatomy  and  pathology. — The  causal  relationship  of 
Pfeiffer's  bacillus  to  influenza  must  be  admitted.  In  addition  to  that 
specific  micro-organism,  the  Diplococcus  pneumoniae,  the  Streptococcus  pyo- 
genes, the  Staphylococcus  aureus,  and  the  Staphylococcus  alius — all  play  more 
or  less  important  though  subordinate  parts.  To  their  presence  many  of  the 
complications  of  this  Protean  disease  are  due.  The  post-mortem  appear- 
ances are  referable  in  the  first  place  to  influenza  itself ;  in  the  next  place, 
and  chiefly,  to  its  secondary  complications  and  sequelse.  Like  other  acute 
specific  infective  diseases,  influenza  causes  parenchymatous  degeneration 
of  the  liver,  kidneys,  and  spleen,  as  well  as  of  the  muscular  substance  of 
the  heart,  and  of  the  minute  vessels. 

Symptomatology. — Influenza  sets  in  with  extreme  suddenness  and 
violence — it  may  be  only  a  few  hours  after  exposure  to  infection.  In  most, 
if  not  in  all  cases,  there  is  an  interval  between  the  reception  of  the  poison 
and  the  development  of  the  symptoms.  The  most  usual  duration  of  this 
interval  seems  to  be  one  or  two  days.  In  the  epidemic  of  1889-90, 
I  observed  many  cases  of  apparent  communication  of  influenza  from 
person  to  person,  but  without  being  able  to  calculate  accurately  the 
duration  of  the  period  of  incubation.  In  one  such  instance,  however,  a 
lady  visited  a  friend  ill  of  influenza  at  2  p.m.,  and  was,  three  hours  later, 
attacked  with  symptoms  of  the  disease — chills,  weakness,  coryza,  lachry- 
mation,  stuffing  of  the  nostrils,  and  loss  of  smell  and  of  taste.  Here,  doubt- 
less, the  virus  clung  to  the  person  or  dress  of  the  first  patient,  and  was 
received  into  the  system  of  the  second,  producing  its  toxic  effects  almost 
at  once. 

Adults  suffer  severely  in  many  cases,  the  symptoms  being  chills,  head- 
ache, often  sleeplessness,  sometimes  delirium ;  pains  in  the  eyeballs,  nape 
of  the  neck,  small  of  the  back,  knees,  and  along  the  margins  of  the  ribs ; 
loss  of  the  special  senses  of  smell,  taste,  and  sometimes  hearing ;  smarting 
of  the  eyes,  photophobia,  lachrymation,  otalgia ;  complete  loss  of  appetite, 
thickly-coated  tongue,  bad  taste  in  the  mouth,  foul  breath,  nausea,  and 
perhaps  vomiting ;  constipation,  but  occasionally  diarrhoea ;  cough,  frequent 
sweating,  loss  of  strength,  fainting.  Of  course  it  is  only  a  selection  from 
these  symptoms  that  is  present  in  a  given  case. 

While  a  constitutional  malady,  influenza  in  individual  cases  spends  its 
violence  on  one  or  other  of  the  great  systems  of  the  body.  Hence  it 
presents  several  well-marked  clinical  varieties,  or  types,  such  as  (1)  the 
nervous,  neuralgic,  or  rheumatoid  type;  (2)  the  catarrhal  and  cardio- 
pulmonary types;  (3)  the  gastric  type;  (4)  the. febrile  type. 

The  nervous  type. — One  of  the  earliest  cases  which  I  saw  in  the 
epidemic  of  1889-90,  belonged  to  this  class.  The  patient  was  seized  on 
the  evening  of  Friday,  December  20,  1889.  The  following  is  the  lady's 
own  account  of  the  attack  : — 

"  Friday,  20th  December  1889. — I  went  to  the  oratorio  at  St.  Patrick's 
Cathedral,  apparently  in  my  usual  health.  Shortly  after  entering  the 
Cathedral  I  felt  chilled,  as  if  cold  water  was  being  poured  down  my  back 
and  legs.  When  I  returned  home  I  warmed  myself  at  a  good  fire,  was 
given  some  hot  wine  and  water,  and  went  to  bed ;  then  my  face  and  head 
got  very  hot  and  uncomfortable,  and  pains  began  in  my  arms,  shoulders, 
and  legs.     All  night  the  pains  were  very  bad,  sometimes  so  sharp  across 


192  GENERAL  DISEASES. 

the  back  of  my  chest  that  I  could  have  cried  out ;  and  although  I  felt 
burning  to  touch,  the  cold-water  sensation  continued.  I  got  no  sleep  that 
night.  Next  day,  about  twelve  o'clock  (mid-day),  I  was  given  a  powder 
(salicylate  of  sodium),  and  in  two  hours  afterwards  another,  which  put  me 
into  a  perspiration.  The  pains  in  my  limbs  got  better,  but  my  head  began 
to  ache  badly,  and  all  day  I  felt  very  ill.  I  suffered  from  great  thirst. 
Saturday  night  slept  better.  Sunday  morning,  about  5  A.M.,  I  wished  for 
a  cup  of  tea,  but  could  not  taste  it.  I  might  as  well  have  been  drinking 
hot  water.  Sunday  evening  pains  had  quite  gone.  I  had  no  headache.  I 
got  up  for  a  while,  but  felt  very  weak.  For  several  days  I  had  no  energy 
for  anything,  the  least  exertion  tired  me.  My  sense  of  taste  did  not  return 
for  four  or  five  days.  I  also  got  a  cough  which  was  very  troublesome. 
Temperature — Friday  night,  101°;  Saturday  morning,  100°;  evening,  98°-8." 

The  nervous  symptoms  of  this  form  of  influenza  arrange  themselves 
under  the  headings — rheumatoid  and  neuralgic  pains  in  the  head,  back  of 
the  eyeballs,  small  of  the  back,  limbs,  and  joints;  lesions  of  sensation, 
including  loss  of  the  senses  of  taste  and  smell ;  various  paralyses,  should 
peripheral  neuritis  or  myelitis  occur  as  a  complication ;  heart  failure,  and 
muscular  prostration.  The  patients  are  often  sleepless  and  delirious,  and  the 
temperature  runs  rather  high  for  three  or  four  days.  Profound  depression 
and  anasmia  are  common  in  the  protracted  convalescence  of  this  type,  and 
relapses  are  very  apt  to  take  place  even  more  than  once.  In  convalescence, 
the  powers  of  the  mind  may  be  shaken — acute  mania  developing,  with  a 
suicidal  impulse ;  or  more  chronic  depression  of  spirits  and  melancholia. 

Cardio-pulmonary  type. — On  Monday,  30th  December  1889,  Mrs.  W., 
a  lady,  set.  54,  somewhat  frail  and  delicate,  while  out  walking  was  seized 
with  shivering  and  violent  headache,  and  intense  pain  in  the  back  and  in 
the  "  bones."  On  reaching  home  she  at  once  went  to  bed,  feeling  very  ill 
and  prostrate.  Next  day  I  visited  her.  The  tongue  was  thickly  furred  and 
dry.  Her  pulse  was  132,  respirations  28,  temperature  103°-3.  Having 
regard  to  the  sudden  onset  of  the  illness  and  the  symptoms,  I  pronounced 
the  attack  to  be  one  of  influenza. 

On  the  third  day  the  pulse  was  110,  respiration  28,  temperature  102°  F. 
The  tongue  thickly  coated ;  eyes  tender,  and  lachrymation ;  complete  ano- 
rexia ;  great  prostration. 

January  2,  1890  (fourth  day). — The  report  was  that  she  had  a  better 
night.  Herpes  was  showing  round  the  nostrils.  Pulse,  96  to  100  ;  respira- 
tion, 28  ;  temperature,  102o-4.  Severe  stabbing  or  catching  pain  was  com- 
plained of  at  the  lower  part  of  the  left  side  of  the  chest.  No  physical  signs 
could  be  detected,  and  a  poultice  relieved  the  pain. 

January  3  (fifth  day). — Pulse,  110;  respiration,  32;  temperature, 
102o-7.  A  lymphy  crepitation  was  now  audible  over  the  upper  part  of  the 
left  side  of  the  chest,  and  on  deep  inspiration  a  fine  pneumonic  crepitation 
could  be  heard. 

January  4  (sixth  day). — Pulse,  110;  respiration,  40;  temperature, 
103o-3.  Dulness  now  existed,  which  was  rapidly  extending  all  over  the 
left  apex,  where  also  a  marked  frottement  could  easily  be  recognised.  At 
6  P.M.,  Dr.  Watson  Pike  saw  the  patient  with  me,  and  agreed  in  my 
diagnosis  of  influenza  complicated  with  a  left  pleuro-pneumonia.  Pulse, 
112;  respiration,  42;  temperature,  102°'7.  There  was  not  a  trace  of 
expectoration,  and  scarcely  any  cough  occurred.  "We  considered  the 
patient  to  be  in  danger,  and  continued  the  treatment,  which  consisted  in 
free  stimulation,  frequent  feeding,  and  quinine. 


INFLUENZA — EPIDEMIC  CATARRHAL  FEVER. 


!93 


At  1.30  a.m.  on  January  5,  I  was  summoned  to  see  the  patient,  and 
found  her  sinking  fast.  Dr.  Hearn  of  Rathmines  kindly  joined  me  in  con- 
sultation. Her  pulse  was  failing,  and  the  temperature  was  103o,3.  She 
rallied  for  a  time,  but  at  6  A.M.  another  attack  of  cardiac  failure  came  on. 
From  this  also  she  rallied,  but  at  10  a.m.  she  suddenly  died.  The  tempera- 
ture chart  (Fig.  29)  gives  the  facts  in  this  case. 

As  bearing  on  the  diagnosis  of  this  case,  it  is  to  be  noticed  that  four — 
if  not  five — of  the  other  members  of  this  lady's  family  suffered  from 
influenza  either  immediately  before  or  after  her  illness. 

Many  of  the  cases  classed  under  the  heading  of  catarrhal  influenza 
develop  symptoms  of  catarrh,  of  the  various  mucous  membranes  lining  the 
respiratory  tract,  at  the  outset.  The  affection  extends  into  the  bronchioles 
and  adjoining  pulmonary  lobules,  constituting  a  broncho-pneumonia,  or 
catarrhal  pneumonia.  In  many  other  instances,  however,  a  lobar  pneu- 
monia ushers  in  the  attack.  This  would  seem  sometimes  to  be  caused  by  a 
secondary  infection  by  the  Biplococcus  pneumoniae,  more  commonly  by  a 
secondary  infection  by  the  Streptococcus  pyogenes — an  etiological  fact  which 


Day  of 
Disease 

2 

3 

4 

5 

6 

7 

F. 
104° 

103° 

102° 

101° 

100° 

99° 

Normal 

38° 

97° 
96° 

; 

! 

a 

> 

X 

r 

;  > 

\\- 

~> 

y 

i 

! 

; 

• 

1 

1 

1 

l 

I 

j 

I 

! 
1 

1 

Pulse 

/r32 

no/ 

110/ 

no/ 
/os 

112/ 

/12 

143/ 

Resp. 

/28 

28/ 

2s/ 

32/ 
/32 

40/ 

/*2 

/ 

Fig.  29. — Influenza — Cardio-  pulmonary. 


Fig.  30. — Influenza — gastric. 


would  explain  the  many-celled  purulent  expectoration,  which  so  often  takes 
the  place  of  the  viscid  rusty  sputum  of  ordinary  lobar  pneumonia. 

Gastric  type. — On  "Wednesday,  January  8,  1890,  Mr.  W.  B.  S.  enjoyed 
a  day's  shooting  in  the  Co.  Wicklow.  The  following  day  he  returned 
to  town  in  his  usual  good  health ;  but  in  the  afternoon  felt  chilly,  com- 
plained of  headache  and  nausea,  and  felt  utterly  miserable.  He  went 
to  bed  early,  but  passed  a  wretched  night — restless  and  sleepless.  Next 
morning  I  found  him  complaining  of  pains  in  the  eyeballs,  back  of  the 
head,  and  small  of  the  back.  Pulse,  84;  temperature,  99°*9;  tongue  thickly 
coated ;  complete  loss  of  appetite  and  nausea.  He  felt  entirely  prostrate, 
and,  at  my  evening  visit,  expressed  his  belief  that  some  fish  which  he  had 
eaten  for  dinner  had  thoroughly  disagreed  with  him.  Two  miserable  days 
of  sickness  followed,  the  temperature  rising  on  the  morning'  of  the  fifth  day 
to  103o,l.  A  short  cough  had  set  in,  and  the  eyes  were  suffused  and 
tender.  There  was  constipation,  and  he  complained  of  weight  and  fulness 
in  the  pit  of  the  stomach.  Dr.  James  Little  saw  him  with  me,  and  thought 
it  likely  that  the  fever  would  run  on  for  some  time.  A  quiet  day  gave 
promise  of  a  restful  night,  and  this  promise  was  abundantly  fulfilled.  He 
had  an  excellent  night,  partly  due  to  20  grs.  of  phenazone  (antipyrine),  with 
vol.  1. — 1^5 


i94 


GENERAL  DISEASES. 


20  minims  of  tincture  of  gelsemium  in  a  draught,  in  divided  doses  at 
bedtime.  Next  morning,  pulse,  76  •;  temperature,  98°-7,  rising  to  100o-2  in 
the  evening,  but  without  any  return  of  restlessness.  Subnormal  tempera- 
tures followed  for  a  few  days — 96°-4  being  one  observation.  The  tongue 
cleaned  very  slowly,  and  several  days  of  extreme  languor  and  weakness 
preceded  final  convalescence.    Fig.  30  includes  the  observations  in  this  case. 

This  gentleman's  wife  had,  a  few  days  previously,  suffered  from  influenza, 
from  which  she  was  recovering  when  he  fell  ill.  She  nursed  him,  and  got  a 
relapse,  accompanied  with  cough,  bronchial  catarrh,  and  absolute  loss  of 
appetite. 

Dawson  Williams  points  out  that  children  in  particular  suffer  from 
the  gastric  form,  and  that,  in  them,  a  sudden  attack  of  vomiting  is  followed 
by  diarrhoea,  the  stools  being  not  infrequently  blood-stained.  There  is 
extreme  prostration.  In  a  case  observed  by  myself  in  January  1890,  a 
boy  of  7 1  years  had  incessant  vomiting  and  nausea  for  twenty-four  hours, 
as  well  as  profuse  sweating,  with  a  pulse  as  fast  as  in  scarlet  fever — 140 


Day  of 
Disease 

2 

3 

4 

5 

6 

7 

8 

F. 
104° 

103° 

102° 

101° 

100° 

S9° 

Normal 

98° 

97° 
96° 

i 

; 

1 

1 

! 

; 

1 

1 

'/ 

\a 

1 

/ 

vf\ 

J 

1 

1 

! 

! 

1 

1 

\| 

j 

«n 

j 

: 

j 

] 

i 

1 

i 

1 

i 

1 

1 

i 

! 

1 

Pulse 

/88 

86/ 
/84 

so?/ 

84/ 

68/ 

Resp. 

22  / 

/22 

23  / 

/ 

Day  0/ 
Disease 

1 

2 

3 

4 

F. 
104° 

103° 

102° 

101° 

100° 

09° 

Normal 
98° 

97° 

96° 
95° 

i 

Pulse 

112  / 

/I30 

120/ 

Resp. 

/ 

/ 

/ 

Fig.  31. — Influenza — febrile. 


Fig.  32. — Influenza  in  child. 


per  minute.  Peacock,  in  his  account  of  the  epidemic  of  1847,  drew 
attention  to  the  frequent  presence  of  slight  jaundice,  nose-bleeding,  and 
albuminuria. 

Febrile  type. — On  New  Year's  Eve,  1889,  I  received  a  note  from  a 
surgical  colleague  asking  me  to  see  him,  as  he  had  been  taken  ill  the  same 
afternoon  while  in  his  study.  On  visiting  him  in  bed,  he  was  still  shivering 
at  times,  and  complaining  of  a  distressing  feeling  of  cold  water  streaming 
down  his  back.  He  stated  that  he  had  been  out  of  sorts  for  three  or  four 
weeks,  and  it  was  quite  evident  that  he  had  made  up  his  mind  that  the 
attack  was  one  of  typhoid  fever.  His  pulse  was  92,  the  temperature  about 
100°.  His  tongue  was  very  furred,  and  his  eyes  were  injected,  with 
swollen  lids.  He  had  lost  the  sense  of  taste  and  smell,  and  complained 
much  of  rheumatoid  or  neuralgic  pains  in  the  back  and  limbs.  Two 
restless  feverish  nights  followed. 

There  was  in  this  case  steady  pyrexia  for  four  days,  and  then  came 
profuse  sweatings,  lasting  for  several  days.  A  slight  elevation  of  tempera- 
ture occurred  on  the  evening  of  the  seventh  day,  after  which  convalescence 
went  on  uninterruptedly.     The  weakness  was  for  a  time  extreme. 

This  febrile  type  prevailed  especially  among  children.     In  three  charts, 


INFLUENZA — EPIDEMIC  CATARRHAL  FEVER. 


i95 


showing  the  febrile  movement  in  girls,  aged  from  12  to  15,  the  marked 
subnormal  temperatures  on  the  third  and  following  days  are  very  note- 
worthy, and  are  so  constantly  present  in  the  defervescing  stage  of  influ- 
enza as  to  become  an  important  diagnostic  sign.  The  charts  (Figs.  31-34) 
illustrate  the  fever  movement  in  influenza  as  it  attacks  children. 

Complications. — I  have  seen  fatal  cases  of  influenzal  bronchitis,  pneu- 
monia, pleuritis,  and  heart  failure.  The  pneumonia,  while  producing 
the  ordinary  physical  signs  of  acute  croupous  pneumonia,  is  often  latent  in 
its  course,  or  accompanied  by  a  profuse  muco-purulent  expectoration,  with 
scarcely  any  rusty  sputa.  The  ebbing  of  the  strength  in  some  of  these 
cases  in  elderly  people  is  something  awful — it  is  often  absolutely  beyond 
control.  Other  complications  of  which  I  have  had  experience  are :  Epis- 
taxis,  facial  neuralgia,  profuse  sweatings,  skin  rashes,  and  cystitis,  followed 
by  mild  orchitis. 

In  contrast  to  dengue  fever,  influenza  is  a  non-eruptive  fever.     When 


Day  of 
Disease 

1 

2 

3 

4 

F. 
104° 

103° 

102° 

101° 

100° 

99° 

Normal 
98° 

97° 

96° 
95° 

! 

; 

i  * 

i 

i 

\>  1 

\ 

j 

i 

i 

V 

1 

t 

\ 

i 

: 

I  \ 

i 

Pulse 

no/ 

Resp. 

Day  of 
Disease 

1 

2 

3 

4 

5 

F. 

104° 

103° 
102° 
101° 

100° 

99° 

Normal 
98° 

S7° 

96° 

95° 

'  % 

\ 

N 

\ 

■ 

; 

\  i 

\ 

A 

/ 

V 

\ 

/ 

! 

i 

i 

i* 

i 

Pulse 

no/ 

Resp. 

Fig.  33. — Influenza  in  child. 


Fig.  34. — Influenza  in  child. 


rashes  do  appear,  they  are  accidental  rather  tnan  essential  or  specific,  and 
they  result  from  hyperpyrexia  or  profuse  sweating,  or  from  the  ingestion 
of  such  drugs  as  quinine,  or  phenazone,  or  salicylate  of  sodium. 

Diagnosis. — Influenza  has  been  looked  on  as  a  variety  of  dengue, 
which,  however,  is  an  eruptive  fever  more  closely  resembling  scarlatina, 
and  prevailing  only  in  tropical  or  subtropical  climates. 

When  typhoid  fever  sets  in  suddenly,  the  'Symptoms  closely  simulate 
those  of  influenza.  The  subsequent  course  of  the  fever  is  quite  different. 
Eegard  should  be  had  also  to  the  prevailing  epidemic,  and  to  the  patient's 
surroundings.  The  application  of  Widal's  test  might  materially  aid  the 
diagnosis. 

The  pneumonia  of  influenza  is  more  prostrating  than  ordinary 
pneumonic  fever.  The  rusty  sputa  of  the  latter  are  usually  wanting,  the 
sputa  are  rich  in  young  cells,  they  are  muco-purulent  or  purulent. 

The  onset  of  smallpox,  with  its  backache,  vomiting,  nausea,  and  foul 
tongue,  may  resemble  influenza;  but  the  course  of  the  two  diseases  is 
entirely  different,  and  due  weight  should  be  given  to  the  prevalence  of 
either  disease  at  the  time. 

A  common  cold  is  not  so  severe,  or  so  prostrating,  as  influenza. 

Prognosis. — Influenza  is  not  directly  a  very  fatal  disease.     In  the 


196  GENERAL  DISEASES. 

epidemic  of  1847,  the  death-rate  was  estimated  at  2  per  cent,  of  the  cases 
observed  in  London.  It  has  probably  not  been  higher  in  the  outbreaks  of 
1889  and  more  recent  years.  An  epidemic  of  influenza,  nevertheless, 
produces  a  startling  and  excessive  increase  in  the  death-rate.  In 
1889-90,  influenza  was  more  pernicious  to  the  population  of  Dublin 
than  the  extreme  cold  of  January  1881,  or  of  February  1895.  It  slew  its 
victims,  not  so  much  directly,  as  by  means  of  complications  and  sequela 
affecting  the  breathing  organs  and  the  heart.  It  spared  the  lives  of 
children  of  tender  years,  but  killed  large  numbers  of  adults  and  those 
advanced  in  life.  According  to  the  registrar-general  for  England,  the 
deaths  directly  attributed  to  influenza  in  England  and  Wales  during  1890 
numbered  4523,  but  he  estimates  the  number  of  deaths  directly  and 
indirectly  due  to  it  at  27,000,  equivalent  to  an  annual  death-rate  of  almost 
1  per  1000.  The  subjects  of  heart  disease  and  of  phthisis  die  off  like  flies 
when  attacked  by  this  affection. 

It  should  not  be  forgotten  that  influenza  predisposes  not  only  to  acute 
pneumonia,  but  to  tuberculosis,  and  that  months  may  elapse  before  the 
shaken  powers  of  mind  as  well  as  body  are  fully  restored  after  an  attack. 

Treatment. — The  management  of  influenza  turns  upon  common-sense 
principles.  In  the  first  place,  "  prevention  is  better  than  cure."  The 
treatment  is  expectant,  palliative,  and  symptomatic.  There  is  no  specific 
for  this  strange  malady,  but  the  physician,  notwithstanding,  may  do  much  to 
aid  his  patient  towards  recovery,  to  assuage  his  suffering,  and  to  prevent  or 
control  complications.  To  struggle  against  his  illness  is  supreme  folly  on 
the  part  of  an  influenza  patient.  On  the  contrary,  he  should  take  to  his 
bed  immediately  on  becoming  aware  that  he  is  attacked.  During  the  acute 
stages,  only  light  fluid  nourishment  should  be  allowed,  at  rather  frequent 
intervals — every  two  hours  or  so.  Chicken-broth,  milk  and  soda-water, 
acidulated  barley-water,  toast- water,  two-milk  whey,  combined  with  equal 
parts  of  egg-water  (that  is,  white  of  egg  whipped  up  and  mixed  with 
cold  water  in  the  proportion  of  two  to  four  whites  to  a  pint  of  water, 
and  strained),1  or  white-wine  whey  only  should  be  allowed,  so  long  as 
the  temperature  is  high  and  the  stomach  is  irritable.  Afterwards  an 
abundant  supply  of  nutritious  and  digestible  food  will  be  needed,  as  well 
as  stimulants  in  the  case  of  elderly  patients. 

Solution  of  the  acetate  or  citrate  of  ammonia  is  recommended  as  a  nrild 
antipyretic  in  the  early  stage.  A  warm  bath,  with  strong  solution  of 
ammonia  added  to  the  water,  relieves  the  distressing  f eeling  of  chilliness  at 
the  outset.  Quinine,  in  moderate  doses  of  2  or  3  grs.  thrice  daily,  usually 
agrees,  and  is  useful.  The  torturing  pains  readily  yield  to  phenazone 
(antipyrine) ;  but  the  remedy  should  be  exhibited  in  small  doses,  and  not 
pushed.     A  most  useful  formula  is  the  following : — 

Phenazoni    .  .  .  .  .         .  gr.  xx 

Tincturse  gelsemii  •  min.  xx 

Aquae  chloroform!         .  .  .  .  ^ij 

Signa. — The  draught,  one-fourth  part  for  a  dose  every  second  or  third 
hour,  as  required. 

Phenazone  is  not  a  safe  remedy  in  childhood  or  in  advanced  life,  or  in 
the  weakly.     Phenacetin  may  then  be  substituted  for  it.     Salicylate  of 

1  That  is,  whey  made  by  adding  one  part  of  buttermilk  to  two  parts  of  fresh  milk,  heated  to 
140°  F,  in  a  saucepan. 


DIPHTHERIA.  197 

sodium,  in  10-gr.  closes,  may  be  given  in  effervescence  with  granular 
effervescent  citrate  or  hydrobromate  of  caffeine,  1  or  2  drms.  in  half  a 
tumblerful  of  water,  twice  or  thrice  daily. 

In  the  depression  of  convalescence,  tonics  are  indicated.  One  of  the 
best  is  nux  vomica,  which  may  be  given  in  the  form  of  the  tincture,  in 
combiuation  with  Schacht's  solution  of  bismuth  and  infusion  of  calumba. 
Liquor  strychninse  hydrochloratis  with  dilute  phosphoric  or  hydrochloric 
acid,  and  tincture  of  orange  peel,  is  an  excellent  "  pick-me-up."  The  dose 
of  the  solution  of  strychnine  should  not  exceed  3  or  5  minims  twice  or  thrice 
daily,  else  headache  and  a  feeling  of  throbbing  and  fulness  may  be  pro- 
duced. This  mixture  may  be  given  in  the  form  of  an  effervescing  draught, 
citric  acid  being  added  to  it,  and  an  alkaline  mixture  of  suitable  strength 
being  separately  prepared.  Tincture  of  lemon  may  be  prescribed  instead 
of  tincture  of  orange  peel,  if  so  desired.  Strychnine  may  also  be  injected 
hypodermically  in  like  doses  to  the  above.  Equal  parts  of  the  official 
liquor  strychnine  and  distilled  water  make  a  suitable  solution  for  hypo- 
dermic injection,  in  10-minim  closes. 

Alcoholic  stimulants  may  be  required  for  a  short  time,  especially  in  the 
presence  of  complications ;  but  they  should  be  taken  as  medicine  in  specified 
quantities,  and  only  as  ordered  by  the  physician.  The  mental  state  of  the 
influenza  patient  renders  alcohol  a  particularly  risky  and  unreliable  remedy  ; 
nor  should  it  be  forgotten  that  the  abuse  of  alcohol  is  a  powerful  predis- 
ponent  to  influenza,  and  a  prime  factor  in  raising  the  mortality  from  it. 

J.  W.  MOOKE. 


DIPHTHEKIA. 

Syn.,  Fr.,  Diphthe'rite ;  Ger.,  Dijjhtherie. 

An  acute  infective  disease  produced  by  the  invasion  of  a  mucous  mem- 
brane— usually  of  the  mouth,  nose,  pharynx,  or  larynx — or  of  an  open 
wound,  by  the  Bacillus  diphtherial,  which  leads  to  the  formation  of  a  false 
membrane,  and  elaborates  poisons  which  produce  constitutional  symptoms, 
frequently  ending  in  widespread  paralysis. 

The  adoption  of  the  diphtheria  bacillus  as  the  criterion  by  which  true 
diphtheria  is  to  be  distinguished  from  other  membranous  inflammations, 
will  probably  involve  some  reconsideration  and  modification  of  the 
older  clinical  view  of  the  disease.  For  it  is  no  uncommon  thing  to  meet 
with  cases  of  sore-throat  which,  though  presenting  but  little,  if  any, 
resemblance  to  the  clinical  type  of  diphtheria,  have  to  be  included  in  the 
category  owing  to  the  presence  of  the  diphtheria  bacillus ;  while,  con- 
versely, cases  exhibiting  many  of  the  clinical  features  of  diphtheria  must 
be  excluded  from  the  list  owing  to  its  absence. 

History. — The  records  from  the  sixteenth  century  onwards,  though 
confused  by  the  juxtaposition  and  intermixture  of  diphtheria  with 
scarlatina  anginosa  and  other  forms  of  putrid  sore-throat,  afford  reliable 
descriptions  of  the  disease,  which  appears  to  have  undergone  little,  if  any, 
modifications  in  its  general  characters.  There  are  good  reasons  for 
believing  that  diphtheria  has  existed  from  the  earliest  times.  Excellent 
accounts  of  diphtheria  in  its  epidemic  form  were  published  by  Starr, 
Huxham,  Fothergill,  Eamsey,  Bard,  and  others  during  the  latter  half  of 
the  eighteenth  century.  During  the  earlier  years  of  the  present  cen- 
tury, croup,  as  it  was  then  styled,  occurred  mainly  in  the  sporadic  form. 


i9§  GENERAL  DISEASES. 

It  reappeared  in  epidemic  form  in  Great  Britain  between  1855  and  1858 
as  part  of  a  sudden  uprising  of  the  malady  in  many  parts  of  the  world. 
In  France  the  epidemic  type  asserted  itself  somewhat  earlier  (Boulogne 
sore-throat),  and  Bretonneau  first  named  the  disease  diphtheria  in  his 
account  of  epidemics  occurring  at  Tours  in  1818-21. 

The  disease  is  endemic  in  many  parts  of  the  United  Kingdom,  both  in 
town  and  country.  It  tends  to  become  epidemic  at  certain  seasons.  The 
broad  geological  features  of  a  district  do  not  appear  to  influence  its  pre- 
valence. On  the  other  hand,  a  damp,  exposed  site,  with  a  wet  surface  soil, 
would  seem  to  favour  it.  Epidemic  prevalence  commonly  begins  in 
September,  reaching  its  highest  point  in  October  or  November,  and  then 
declines  slowly  in  December  and  January.  At  times  a  small  recrudescence 
is  observed  in  March  or  April.  The  fatality  of  different  epidemics  varies 
within  wide  limits.  In  some  the  disease  is  rarely  fatal,  whilst  in  others 
the  constitutional  symptoms  are  severe,  and  laryngeal  and  nasal  complica- 
tions are  frequent.  During  the  last  twenty  years  there  has  been  a  pro- 
gressive increase  in  the  rate  of  mortality  from  diphtheria  in  England  and 
Wales,  and  along  with  this  a  wider  diffusion  of  the  disease,  and  apparently 
some  shifting  of  its  incidence  from  rural  districts  to  urban  populations. 
It  is  worthy  of  note  that  this  increase  coincides,  in  point  of  time,  with 
a  progressive  improvement  in  sanitary  circumstances  generally,  and  with  a 
continuous  diminution  in  the  death-rate  from  most  of  the  other  acute 
infectious  diseases  (Thome). 

.  Diphtheria  sometimes  complicates  scarlet  fever  and  measles,  and  more 
rarely  other  infectious  diseases.  Women  and  girls  are  attacked  more 
frequently  than  boys  and  men,  probably  because  of  their  greater  oppor- 
tunities of  coming  into  close  contact  with  the  sick,  and  partly,  it  may  be, 
on  account  of  the  greater  prevalence  among  them  of  the  habit  of  kissing. 
During  the  age  period  5-10,  girls  are  one-third  more  liable  than  boys. 

The  influence  of  age  is  very  marked  both  as  regards  attack-rate  and 
mortality.  Speaking  generally,  it  may  be  said  that  there  is  a  special 
incidence  of  diphtheria  on  the  age  period  3-12.  The  fatality  of  the 
disease  is  very  high  in  the  first  quinquennium  of  life,  and  highest  of  all  in 
infants  under  2  years  of  age.  It  falls  sensibly  after  the  tenth  year  to  rise 
again  after  40.  These  features  of  the  disease  are  well  illustrated  by  the 
accompanying  table  (Goodall  and"  Washbourn),  which  shows  the  numbers 
and  ages  of  the  patients  admitted  into  the  hospitals  of  the  Metropolitan 
Asylums  Board  during  the  years  1888  to  1894,  with  the  number  of  deaths 
and  fatality  per  cent.: — 


Ages. 

Number  Admitted. 

Deaths. 

Fatality. 

Under  1 

199 

123 

61-8 

1  —  2 

688 

434 

63-1 

2  —  3 

966 

532 

55-1 

3  —  4 

1,259 

608 

48-3 

4  —  5 

1,323 

4,435 

516 
2,213 

39-0 

Total  under  5, 

49-9 

5—10 

3,723 

1,046 

28-1 

10—15 

1,330 

141 

10-6 

15—20 

782 

34 

4-3 

20—25 

543 

25 

4-6 

25—30 

354 

19 

5'4 

30—35 

183 

9 

4-9 

35—40 

110 

5 

4-5 

40  and  upwards, 

138 

24 

17-4 

Totals, 

11,598 

3,516 

30-3. 

DIPHTHERIA.  199 

Etiology. — Nature  of  infection. — Diphtheria  is  highly  contagious. 
The  contagium  (the  Bacillus  diphtherial)  is  usually  conveyed  out  of  the 
body  with  the  pharyngeal,  buccal,  or  nasal  secretions. 

It  does  not  appear  to  diffuse  itself  readily  through  the  air  ;  at  any  rate 
those  brought  into  close  contact  with  the  sufferers  are  the  most  likely  to 
become  infected.  Virulent  diphtheria  bacilli  have  on  many  occasions  been 
found  in  the  mouths  of  healthy  individuals,  and  of  persons  who,  in  every 
other  respect,  have  completely  recovered  from  an  attack  of  diphtheria. 
The  bearing  of  these  observations  on  the  manner  in  which  the  disease  may 
spread  is  obvious.  The  contagium  readily  attaches  itself  to  clothes, 
bedding,  etc.,  and  may  exhibit  considerable  vitality  outside  the  body. 
In  one  instance  within  the  writer's  knowledge,  outbreaks  of  the  disease 
continued  to  recur  at  intervals  in  an  hospital  ward,  in  the  face  of  the  most 
stringent  precautions,  until  the  old  flooring  had  been  entirely  removed  and 
replaced  by  a  new  one. 

Among  the  children  of  the  poor,  the  common  practice  of  passing  sweets 
from  mouth  to  mouth  affords  a  ready  means  of  spread.  Occasionally  the 
disease  is  acquired  by  the  direct  inoculation  of  a  wound  or  abrasion,  or  the 
poison  may  be  introduced  with  the  food  (see  Milk  infection).  Direct 
infection  from  person  to  person  is,  however,  the  common  way  in  which 
diphtheria  is  communicated. 

The  question  of  school  influence  on  the  spread  of  diphtheria  has  occupied 
attention  for  many  years.  Some  of  the  ways  in  which  it  appears  to  be 
operative  for  mischief  have  been  summarised  by  Thorne  as  follows  : — 

"  1.  It  brings  together  those  members  of  the  community  who  are,  by 
reason  of  age,  most  susceptible  to  diphtheria. 

"  2.  The  children  thus  brought  together  are  placed,  and  remain  for 
many  hours  of  the  day,  in  exceptionally  close  relation  to  each  other. 

"  3.  The  closer  the  aggregation  and  the  greater  the  hindrance  to  free 
movement  of  air,  the  greater  the  risk. 

"  4.  Faulty  sanitary  conditions  of  the  schoolhouse  and  its  surroundings, 
and  such  other  conditions  as  tend  towards  a  state  of  general  ill-health,  in 
so  far  as  they  induce  sore-throat,  favour  the  reception  of  any  imported 
diphtheria  infection. 

"  5.  The  practices  of  kissing  and  of  transferring  sweetmeats  from  mouth 
to  mouth, — practised  more  commonly  among  girls  than  boys, — the  joint  use 
of  drinking  cups  and  the  like,  must  assist  in  the  diffusion  of  diphtheria 
amongst  school-fellows." 

It  has  been  shown  in  several  epidemics  of  diphtheria,  that  while  the 
schools  remained  open,  the  rate  of  attack  among  children  between  3  and 
12  years  of  age,  who  were  presumably  susceptible  to  the  disease,  was  from 
two  to  four  times  greater  in  those  attending  school  than  in  those  remaining 
at  home.  More  recently,  attention  has  been  directed  to  the  sudden  drop 
in  the  notifications  of  diphtheria  in  London  during  the  ordinary  late 
summer  holiday  period,  and  to  the  increase  which  follows  the  re-opening 
of  the  schools.  Shirley  Murphy,  who  drew  attention  to  this  phenomenon, 
attributes  it  to  diminished  prevalence  at  the  school  age  period  of  life 
during  the  holidays.  There  seems  little  doubt  that  school  influence  must 
be  reckoned  a  feature  of  some  importance.  The  data  at  present  available 
hardly  admit  of  an  exact  statement  being  made  of  the  extent  to  which  it 
is  operative  in  the  spread  of  the  disease.  It  would  appear  to  lie  some- 
where between  5  and  20  per  cent,  of  the  cases  occurring  during  the  school 
age  period  (3-12  years). 


200  GENERAL  DISEASES 

Transmission  by  milk. — There  is  evidence  that  diphtheria  may  be 
transmitted  by  infected  milk,  and  many  extensive  outbreaks  of  the  disease 
have  been  traced  to  this  agency.  The  sufferers  are  mostly  to  be  found 
among  the  milk  consumers  in  affected  households,  especially  where  raw  milk 
is  habitually  consumed.  Stored  milk,  whether  in  the  form  of  cream  or 
skim-milk,  appears  to  be  more  potent  for  mischief  than  fresh  milk.  It 
has  been  shown  that  the  diphtheria  bacillus  will  multiply  in  milk  at 
temperatures  of  from  64°-4  to  68°  F.  Exposure  of  milk,  in  whatever  way, 
to  the  contaginm  of  human  diphtheria  may  therefore  lead  to  its  infection. 
According  to  some  observers,  the  infection  in  certain  outbreaks  is  derived 
from  the  cow.  The  disease  does  not  appear  to  be  capable  of  transmission 
through  the  agency  of  drinking  water. 

Communication  by  animals. — Cats  suffer  from  a  pseudo-membranous 
infective  disease  resembling  diphtheria,  and  many  instances  have  been 
recorded  which  seem  to  show  that  human  diphtheria  may  be  derived  from 
a  cat  so  diseased.  It  has  been  suggested  that  the  disease  in  the  cat  may 
be  contracted  in  the  first  instance  from  a  human  case,  and  transmitted 
from  cat  to  cat.  The  identity  of  the  two  diseases  is  accepted  by  some 
authorities  in  this  country.  The  so-called  diphtheria  of  fowls  is  associated 
with  a  bacillus  which  differs  in  many  ways  from  that  of  diphtheria. 
Loir  and  Duclaux  have  recorded  a  case  of  membranous  sore-throat 
in  a  child,  which  occurred  during  the  prevalence  of  an  epidemic  of  avian 
"  diphtheria."  They  obtained  from  the  false  membrane  typical  cultures 
of  the  bacillus  of  avian  diphtheria,  but  failed  to  discover  the  Bacillus 
diphtherice. 

Influence  of  surroundings. — Very  little  is  known  at  present  of  the 
life  history  of  the  diphtheria  bacillus  outside  the  human  body.  It  is 
capable  of  persisting  for  many  weeks  in  the  throats  of  persons  who  have 
recovered  from  the  disease,  and  may  be  found  in  the  throat  or  clothing 
of  those  in  close  attendance  on  cases  of  diphtheria,  and  in  the  dust  of 
diphtheria  wards.  It  is  probable  that  the  diffusion  of  the  virus  about 
cases  of  diphtheria  is  considerable.  As  regards  the  influence  of  sanitary 
circumstances,  Thorne  makes  the  following  observation:  "That  the  only 
available  vital  statistics  as  to  diphtheria  do  not  support  the  contention 
that  this  disease  and  its  increase  in  this  country  are  related  to  faulty 
sanitary  circumstances;  that  much  diphtheria  which  in  former  times 
would  undoubtedly  have  been  assigned  to  faulty  sanitary  circumstances 
is  now  found  to  be  communicated  to  man  through  the  agency  of  milk; 
that  there  are  good  reasons  for  believing  that  sore  throats  which  are 
induced  by  exposure  to  conditions  such  as  drain  emanations,  render  people 
especially  susceptible  to  the  influence  of  the  diphtheria  contagion";  and 
that  amongst  those  attacks  "  in  which  there  is,  in  appearance  at  least,  a 
connection  between  exposure  to  foul  emanations  and  diphtheria,  some  of 
them  may  possibly  be  instances  in  which  a  process  of  development,  even  in 
the  same  person,  leads  from  a  minor  affection  up  to  a  major  and  definitely 
specific  disease." 

Bacteriology. — The  bacillus  of  diphtheria  is  found  in  every  case  of 
true  diphtheria.  In  length  it  varies  from  2  to  3  ^,  and  in  thickness 
from  0-5  to  0-8  //,.  The  bacilli  are  straight  or  slightly  curved  motionless 
rods,  disposed  in  irregular  clusters  or  in  parallel  bundles,  but  never  in 
chains.  A  long  and  a  short  variety  are  commonly  recognised.  The  short 
rods  are  often  somewhat  thickened  at  one  end,  or  present  a  swollen  centre 
tapering  towards  rounded   extremities.      Curious   club-shaped   or   pear- 


DIPHTHERIA.  201 

shaped  involution  forms1  occur  both  in  cultivations  and  in  false  mem- 
brane. The  bacilli  stain  readily  by  Gram's  method  or  with  alkaline 
methylene-blue.  The  segmented  appearance  presented  by  some  stained 
preparations  is  due  to  metachromatism.  Sporulation  does  not  occur.  The 
Klebs-Lonier  bacillus  grows  readily  on  serum  at  37°  C. 

The  pseudo-diphtheria  bacillus  (Hofmann's  bacillus)  is  sometimes  met 
with  in  the  throats  of  patients  suffering  from  true  diphtheria.  The  rods 
are  short,  wedge-shaped,  and  generally  united  in  pairs,  with  the  bases  in 
apposition.  The  colonies  are  practically  indistinguishable  from  those  of 
true  diphtheria,  and  old  cultivations  similarly  present  clubbed  forms. 
Hofmann's  bacilli  stain  uniformly.  They  differ  in  the  main  from  those  of 
true  diphtheria  in  being  non-pathogenic  to  animals.  Goodall  and  Wash- 
bourn  give  the  following  directions  for  making  a  bacteriological  examina- 
tion in  cases  of  suspected  diphtheria : — 

"  The  tongue  is  depressed  with  a  spatula,  and  a  portion  of  the  exudation 
is  removed  by  scraping  or  rubbing  over  the  fauces  with  a  sterilised  instru- 
ment. For  this  purpose  either  a  platinum  rod  is  employed,  which  can  be 
sterilised  in  a  flame  just  before  use ;  or  a  plug  of  cotton-wool  fixed  on  the 
end  of  a  metal  rod,  previously  sterilised,  and  kept  in  a  sterilised  test-tube 
plugged  with  cotton-wool.  In  laryngeal  cases,  if  the  fauces  are  not  visibly 
affected,  the  instrument  must  be  passed  as  far  as  possible  downwards 
towards  the  larynx.  Two  or  three  blood-serum  tubes  are  then  inoculated 
by  smearing  their  surface  with  the  platinum  rod  or  plug  of  cotton-wool. 
The  tubes  are  placed  in  an  incubator  and  kept  at  the  body  temperature. 
At  the  end  of  twelve  or  eighteen  hours  the  diphtheria  colonies  appear  as 
opaque,  white,  round  masses  the  size  of  a  pin's  head.  On  microscopical 
examination,  a  diagnosis  can  be  made.  A  portion  of  one  of  the  colonies  is 
removed  with  a  sterilised  platinum  wire,  is  diluted  with  a  drop  of  water, 
and  spread  over  the  surface  of  a  cover-glass.  The  cover-glass  is  allowed  to 
dry  in  the  air,  is  passed  three  times  through  a  flame,  and  is  stained  for  five 
minutes  in  a  solution  of  carbolic  methylene-blue.2  The  cover-glass  is  then 
washed  with  water,  dried  in  air,  mounted  on  a  slide  with  Canada  balsam, 
and  examined  with  a  one-twelfth  oil-immersion  lens.  Should  the  case  be 
one  of  diphtheria,  bacilli  with  the  characters  already  mentioned  will  be 
found. 

"  If  the  exudation  on  the  throat  be  examined  directly  under  the  micro- 
scope it  will  in  all  cases  show  a  number  of  different  kinds  of  bacteria. 
Many  of  these  bacteria  are  the  normal  inhabitants  of  the  mouth,  and  do 
not  form  colonies  on  blood  serum.  Consequently  in  some  cases  of  diphtheria 
the  only  colonies  which  develop  in  the  tubes  are  those  of  the  diphtheria 
bacillus.  But  in  the  majority  of  cases  other  colonies  also  develop.  The 
most  important  of  these  are  minute  transparent  colonies  of  a  streptococcus 
similar  to,  if  not  identical  with,  the  streptococcus  pyogenes.  .  .  .  "We 
must  add  that  a  single  bacteriological  examination  will  not  always  detect 
the  presence  of  diphtheria  bacilli,  even  in  cases  of  undoubted  diphtheria. 
This  may  be  due  to  the  cultivation  having  been  taken  from  an  area  free 
from  bacilli,  to  the  local  use  of  antiseptics,  or  to  some  error  of  examination." 

In  cases  of  laryngeal  diphtheria  the  bacilli  should  be  sought  for  in  the 
pharyngeal  or  faucial — not  tonsillar — secretions.     As  a  rule,  the  bacilli 

1  There  is  still  sonic  difference  of  opinion  as  to  the  nature  and  significance  of  these  aberrant 
forms. 

a  Loffier's  alkaline  methylene-blue  solution  may  also  be  used  with  advantage.  It  is  pre- 
pared as  follows : — Concentrated  alcoholic  solution  of  methylene-blue,  30  c.c.  ;  solution  of 
caustic  potash  (O'Ol  per  cent.),  100  c.c. 


202  GENERAL  DISEASES. 

obtained  from  cultures  are  somewhat  smaller  than  those  obtained  directly 
from  false  membrane. 

Mixed  infection  is  the  term  applied  to  cases  in  which  considerable 
numbers  of  pyogenic  bacteria  (streptococci  especially)  are  found  associated 
with  the  diphtheria  bacillus.  It  is  held  by  some  Continental  observers 
that  their  presence  is  of  unfavourable  import,  but  this  view  is  not 
supported  by  observations  made  in  this  country.  There  can  be  no  doubt, 
however,  that  these  organisms  may  produce  secondary  septic  complica- 
tions, and  many  cases  of  septic  and  hemorrhagic  diphtheria  are  probably 
largely  due  to  their  agency. 

Membranous  affections  resembling  diphtheria,  at  times  closely  resembling 
diphtheria  clinically,  may  occur  in  association  with  other  micro-organisms. 
This  is  notably  the  case  in  the  sore  throat  of  scarlet  fever,  where  strepto- 
cocci or  other  pyogenic  bacteria  are  met  with.  Not  infrequently,  however, 
patients  suffering  from  scarlet  fever  have  true  diphtheria  bacilli  in  their 
fauces,  and  the  two  diseases  may  occur  simultaneously  or  consecutively  in 
the  same  patient.1 

In  many  cases  of  acute  follicular  tonsillitis,  particularly  among  children, 
the  exclusion  of  diphtheria  can  only  be  made  with  certainty  by  bacterio- 
logical examination.  Membranous  affections  of  the  throat  have  also  been 
described  in  association  with  measles,  typhoid  fever,  and  whooping-cough, 
which  are  not  necessarily  associated  with  the  diphtheria  bacillus.  Experi- 
ence tends  to  show  that  these  non-diphtherial  membranous  affections  are 
rarely  communicated  to  others.  Their  occurrence  in  the  course  of  the 
acute  specific  fevers  is  often  of  grave  import,  and  in  many  cases  septicaemia 
accelerates  a  fatal  issue.     Paralysis  does  not  occur. 

Morbid  anatomy. — With  the  exception  of  false  membrane,  there 
are  few  macroscopic  changes  after  death  from  diphtheria.  The  position 
and  extent  of  the  membrane  naturally  varies  considerably.  It  is  to  be 
found  in  most  cases  on  the  tonsils  and  fauces  and  contiguous  mucous 
membranes,  but  may  be  entirely  limited  to  the  larynx  and  air  passages,  or 
to  the  nose.  It  is  often  more  adherent  over  the  tonsils  and  pharynx  than 
in  other  situations.  False  membrane  may  occasionally  be  traced  down- 
wards into  the  smallest  bronchi;  but  more  usually  after  the  second  or 
third  branchings  the  membranous  structure  insensibly  passes  into  a  muco- 
purulent non-adherent  material.  The  consistence  of  the  membrane  varies 
greatly  in  different  cases,  peeling  off  in  large  flakes  in  some,  whilst  in 
others  it  is  pultaceous  or  shreddy  and  friable.  In  very  malignant  cases 
there  may  be  necrosis  of  the  mucous  membrane  and  sloughing  of  the  tonsils 
and  palate.  Where  the  false  membrane  has  separated  before  death,  there 
is  often  a  granular  appearance  of  the  mucous  membrane. 

Diphtheritic  false  membrane  consists  of  a  fibrinous  meshwork  enclos- 
ing masses  of  dead  epithelium  and  leucocytes  and  some  red  blood  cells. 
The  cellular  constituents  are  derived  from  the  superficial  layers  of  the 
epithelium,  together  with  migrating  leucocytes  which  are  destroyed  by  the 
poison  and  with  the  surrounding  elements  undergo  hyaline  transformation 

1  An  examination  of  100  consecutive  cases  sent  to  the  Eastern  Hospital  certified  to  have 
scarlet  fever  showed  the  following  restdts  (Goodall) :  eighty-seven  had  scarlet  fever,  and  in 
&ix  of  these  there  were  diphtheria  bacilli  of  the  long  variety.  In  thirteen  cases  the  short 
variety  only  of  the  bacillus,  or  organisms  indistinguishable  from  it,  were  found.  Of  the 
thirteen  other  cases,  two  were  cases  of  diphtheria,  five  were  cases  of  rbtheln,  in  one  of  which 
the  short  variety  of  the  diphtheria  bacillus  was  found  ;  three  were  cases  of  measles,  one  a 
case  of  pneumonia  with  the  short  variety  of  the  diphtheria  bacillus,  one  a  case  of  diarrhoea, 
and  one  a  case  of  tuberculous  meuinsitis. 


DIPHTHERIA.  203 

(coagulation-necrosis  of  Weigert).  The  subjacent  epithelium  is  usually 
destroyed,  and  no  definite  line  of  demarcation  can  be  made  out  between  it 
and  the  false  membrane.  The  deeper  layers  of  the  mucous  membrane  may 
be  infiltrated  with  fibrin  and  leucocytes,  and  may  exhibit  areas  of  hyaline 
transformation.  The  formation  of  these  foci  of  necrobiosis,  starting  from 
the  epithelium  and  proceeding  inward,  is,  according  to  Oertel,  the  distin- 
guishing characteristic  of  diphtheria.  The  diphtheria  bacilli  are  generally 
found  at  or  near  the  surface  of  the  false  membrane,  and  in  some  cases  they 
have  been  obtained,  after  death,  from  the  spleen,  kidneys,  and  lymphatic 
glands.  In  cases  complicated  by  streptococcus  infection,  these  organisms 
may  be  found  in  the  mucous  membrane  and  in  septicemic  lesions  of  the 
internal  organs. 

The  visceral  and  other  changes  met  with  are  variable.  In  laryngeal 
cases  areas  of  collapse,  which  are  often  extensive,  and  patches  of  lobular 
pneumonia  are  usually  present  in  the  lungs.  Diphtheria  bacilli  can  often 
be  cultivated  from  the  alveolar  contents  in  such  cases.  Accumulation  of 
muco-pus  in  the  bronchi  is  often  met  with,  especially  after  tracheotomy. 
Wholesale  collapse  of  the  lung,  sometimes  affecting  an  entire  lobe,  is  a 
common  event  in  cases  in  which  the  diaphragm  or  intercostal  muscles  have 
been  profoundly  paralysed.  The  right  lower  lobe  appears  more  liable  to 
be  affected  in  this  way  than  any  other  part  of  the  lungs.  The  cervical  and 
submaxillary  glands  are  nearly  always  swollen  and  firm  on  section.  The 
bronchial  glands  are  similarly  affected  where  there  have  been  pulmonary 
complications.  Foci  of  suppuration  in  the  lymphatic  glands  are  very 
exceptional.  Swelling  of  the  solitary  glands  of  the  intestine  and  of  Peyer's 
patches  is  frequently  well  marked,  but  ulceration  does  not  occur.  In  such 
cases  the  mesenteric  glands  are  also  enlarged.  The  spleen  is  generally 
somewhat  enlarged  and  firm.  Cloudy  swelling  of  the  spleen,  liver,  and 
kidneys  is  usually  present.  The  kidneys  may  appear  quite  normal  even 
where  there  has  been  albuminuria,  or  may  exhibit  varying  degrees  of 
parenchymatous  inflammation,  especially  where  signs  of  acute  nephritis  or 
suppression  of  urine  have  been  present. 

The  right  cavities  of  the  heart  often  contain  a  considerable  quantity  of 
decolorised  clot,  more  or  less  adherent  according  to  the  slowness  with  which 
death  has  taken  place.  Inflammation  of  the  endocardium  is  hardly  ever 
met  with.  Pericarditis  is  equally  rare.  Granular  or  fatty  changes  in  the 
myocardium  are  by  no  means  uncommon,  and  are  present  in  most  cases 
where  death  was  due  to  cardiac  failure.  Cardiac  syncope  has  been 
attributed  by  some  observers  to  an  interstitial  myocarditis.  When  death 
occurs  at  a  later  stage,  in  the  course  of  a  multiple  paralysis,  the  heart 
presents  the  appearances  usually  found  in  death  from  asphyxia.  The 
right  cavities  are  distended  with  blood  and  black  clot,  and  subpericardial 
and  subpleural  ecchymoses  are  not  uncommon.  There  may  be  myocardial 
changes,  but  the  symptoms  point  rather  to  a  lesion  of  the  cardiac  nerves 
as  the  cause  of  heart  failure  in  these  cases. 

Degenerative  changes  have  been  found  both  in  the  medulla  and  spinal 
cord  and  in  the  peripheral  nerves.  The  prevailing  opinion  is  that  the 
latter  is  the  chief,  and  often  the  only  cause  of  the  paralysis.  The 
affected  nerves  do  not  degenerate  in  their  whole  extent.  In  the  affected 
segments  the  white  substance  of  Schwann  is  broken  up  and  attenuated. 
The  axis  cylinder  may  remain  intact,  or  become  ruptured,  whilst  the 
primitive  sheath  remains  unaffected.  There  is  no  interstitial  change.  It 
is  a  degeneration  of  the  nerve  fibre  itself  (Sidney  Martin).    Similar  changes 


2o4  GENERAL  DISEASES 

occur  in  the  sensory  and  sympathetic  nerves.  On  the  other  hand,  a  true 
interstitial  neuritis  may  affect  the  nerves  of  the  palate. 

Haemorrhages  are  usually  met  with  in  cases  of  extreme  malignancy. 
On  the  surface  they  occur  in  the  form  of  petechias  or  ecchymoses,  and 
internally  are  chiefly  met  with  in  the  serous  membranes,  loose  areolar 
tissues,  muscles,  and  alimentary  canal. 

Symptomatology. — Diphtheria  is  at  the  outset  a  local  affection. 
The  constitutional  symptoms  are  due  to  the  absorption  into  the  system 
of  soluble  poisons  produced  by  the  bacilli  at  the  seat  of  the  local  disease. 
The  severity  of  the  constitutional  symptoms  is  proportional  to  the  degree 
of  infection ;  i.e.  to  the  dose  of  poison  absorbed  from  the  primary  lesion. 
Speaking  generally,  there  is  a  correspondence  between  the  extent  of  the 
local  affection  and  the  severity  of  the  general  symptoms.  The  term  simple 
or  benign  is  applied  to  cases  in  which  the  general  disturbance  is  slight, 
the  term  malignant  to  those  in  which  the  toxaemia  is  profound. 

Incubation.  —  This  is  always  short ;  often  two  days,  sometimes  three 
or  four,  probably  never  exceeding  seven. 

Invasion. — This  is  often  unobtrusive  or  insidious,  but  a  sudden  onset, 
with  or  without  rigor  or  chills,  is  not  uncommon.  The  early  symptoms 
are  mainly  those  of  fever — chilliness,  headache,  shifting  pains  in  back  and 
limbs,  nausea,  and  general  malaise.  In  infants  the  onset  may  be  heralded 
by  convulsions  and  vomiting.  Sore-throat  may  be  complained  of,  but  is 
often  very  slight  or  absent  at  first.  In  infants  difficulty  in  swallowing  or 
disinclination  for  food  are  of  common  occurrence. 

Course.  —  It  will  be  convenient  to  begin  with  a  description  of  the 
symptoms  of  an  ordinary  uncomplicated  case  of  faucial  diphtheria.  The 
initial  rise  of  temperature  is  generally  moderate ;  100°— 102°  F.,  sometimes 
higher.  The  fauces  are  usually  swollen  and  dusky  red,  though  occasionally 
pale  and  glistening  before  the  appearance  of  membrane.  The  breathing 
is  somewhat  hurried,  and  the  pulse  rate  increased.  The  urine  presents 
the  usual  febrile  characters,  and  may  contain  a  trace  of  albumin. 

The  development  of  the  disease  is  rapid.  "Within  a  few  hours  of  the 
onset  there  may  already  be  indications  of  false  membrane  in  the  shape  of 
one  or  more  whitish  specks  or  patches  on  the  tonsils  or  fauces.  At  this 
stage  the  appearance  of  the  throat  may  closely  resemble  that  of  acute 
follicular  tonsillitis.  Sometimes  the  appearance  of  the  exudation  is  delayed 
for  several  days,  and  rarely  the  local  inflammation  is  unaccompanied  by 
membrane.  In  the  majority  of  cases  false  membrane  is  already  present 
when  the  patient  first  comes  under  observation.  The  patches  of  false 
membrane,  which  may  be  ill-defined  at  first,  soon  increase  in  size  and 
consistency,  and  may  extend  so  rapidly  as  to  cover  the  whole  of  the  fauces 
and  pharynx  within  forty-eight  hours.  There  is  generally  considerable 
oedema  of  the  affected  area,  so  that  on  looking  into  the  mouth  the  opening 
of  the  fauces  is  more  or  less  obliterated.  The  colour  and  consistency  of 
the  false  membrane  vary  considerably.  At  first  it  is  whitish  or  yellowish 
white,  of  varying  opacity,  and  somewhat  loosely  adherent ;  as  it  increases 
in  thickness  and  extent,  it  tends  to  become  more  yellow  or  even  brown 
and  leathery,  and  can  only  be  removed  with  some  difficulty,  leaving  a  raw- 
looking  surface  with  bleeding  points.  New  membrane  rapidly  takes  the 
place  of  that  which  has  been  removed.  There  is  generally  more  or  less 
mucous  exudation  and  accumulation  about  the  fauces,  and  sometimes 
signs  of  coryza  and  a  thin  acrid  discharge  from  the  nostrils.  As  the  local 
lesion  extends,  the   general   symptoms   increase   in   severity,  and  throat 


DIPHTHERIA.  205 

symptoms  become  more  prominent.  Anaemia  and  bodily  weakness  become 
marked,  and  in  severe  cases  the  surface  may  present  a  dusky  hue.  The 
glands  at  the  angles  of  the  jaws  and  their  lymphatic  connections  become 
swollen,  painful,  and  tender.  The  pulse  is  frequent,  small,  and  compress- 
ible. The  tongue  is  thickly  furred  on  the  dorsum,  and  tends  to  become 
dry.  Appetite  quickly  fails,  but  is  seldom  totally  lost.  Mastication  and 
swallowing  may  be  difficult  and  painful,  though  rarely  to  the  same  extent 
as  in  acute  follicular  tonsillitis.  The  temperature  ranges  irregularly 
between  100°  and  102°,  but  may  occasionally  reach  103°  or  even  higher. 
In  an  uncomplicated  case  the  chest  will  reveal  nothing  on  examination, 
unless  it  be  scanty  signs  of  bronchial  catarrh.  In  a  large  proportion  of 
cases  the  urine  contains  albumin.  In  a  favourable  case  the  symptoms 
may  begin  to  subside  as  early  as  the  fourth  or  fifth  day,  more  often  at  the 
end  of  a  week  or  ten  days.  The  membrane  ceases  to  spread,  and  is  thrown 
off  in  flakes  or  shreds  and  does  not  re-form.  The  swelling  of  the  neck 
subsides,  and  convalescence  begins. 

Varieties. — Deviations  from  this  favourable  course  are  frequent,  and 
are  due  partly  to  extension  of  the  local  disease  in  various  directions,  partly 
to  the  degree  of  systemic  infection. 

Benign  diphtheria  has  usually  limited  local  disease,  and  the  con- 
stitutional symptoms  are  very  mild  and  indefinite.  Fever  is  slight  or 
absent ;  slight  soreness  of  throat  on  swallowing  may  be  complained  of 
for  a  day  or  two,  and  on  examination  one  or  two  loosely  adhering  patches 
of  membrane  may  be  seen  on  the  tonsils,  though  they  may  already  have 
disappeared  when  the  patient  comes  under  observation.  Anseniia  and 
debility  are  nearly  always  present,  and  may  be  the  most  striking  features 
of  the  illness.  Some  enlargement  of  the  cervical  glands  is  also  common. 
There  can  be  no  doubt  that  many  cases  of  this  nature  escape  notice  alto- 
gether, and  may  be  important  factors  in  spreading  the  disease.  It  is 
further  to  be  observed  that  the  mildness  of  the  primary  disease  does  not 
exempt  the  patient  from  the  risk  of  complications  or  dangerous  sequelae. 
Exceptionally  there  may  be  extensive  local  disease  with  very  slight  con- 
stitutional disturbance. 

Malignant  diphtheria  is  characterised  by  severity  rather  of  the  con- 
stitutional symptoms  than  of  the  local  lesions.  The  virulence  of  the 
attack  may  manifest  itself  from  the  outset,  but  severe  systemic  symptoms 
commonly  make  their  appearance  somewhat  later.  Prostration  is  extreme, 
the  surface  often  dusky  or  ashen  grey,  the  pulse  rapid  and  feeble,  the 
tongue  dry,  the  fever  often  high,  though  occasionally  the  temperature  may 
be  normal  or  even  subnormal.  The  urine  is  albuminous,  but  very  rarely 
bloody.  Erythematous  or  petechial  eruptions  are  not  uncommon,  and 
there  may  be  bleeding  from  the  mucous  membranes  and  into  the  cellular 
tissues  (haemorrhagic  diphtheria).  Extension  of  the  inflammation  to  the 
nose  is  a  common  feature  of  malignant  diphtheria.  Throat  symptoms, 
however,  are  not  necessarily  prominent.  Even  in  the  most  malignant 
form  of  the  disease,  which  kills  by  intense  toxaemia,  the  appearances  may 
differ  but  little  from  those  presented  by  a  case  of  ordinary  severity.  Some- 
times the  membrane  becomes  dark  and  pultaceous  from  decomposition,  and 
imparts  an  offensive  odour  to  the  breath.  This  condition  has  been  mis- 
taken for  gangrene.  In  other  cases,  very  great  swelling  of  the  fauces  and 
underlying  tissues  is  associated  with  a  thin  and  ill-defined  exudation. 
Extension  of  the  local  inflammation  to  the  deeper  structures  is  usually 
attended  by  marked  swelling  of  the  cervical  glands  and  connective  tissues, 


2o6  GENERAL  DISEASES. 

and  at  times  the  whole  neck  becomes  deformed  by  diffuse  brawny  swelling 
from  the  jaw  to  the  collar  bones.  Gangrene  and  deep  ulceration  at  the 
mucous  surface,  extravasations  of  blood,  and  suppuration  in  the  deeper 
tissues  of  the  neck,  are  all  of  rare  occurrence.  The  heart  usually  fails 
rapidly,  and  in  most  cases  death  by  asthenia  takes  place  within  a  short 
time,  or  quite  suddenly  from  syncope. 

Extension  of  alse  membrane.  —  This  may  take  place  in  several 
directions : — (a)  Into  the  larynx  and  trachea ;  (5)  into  the  nasal  cavities, 
along  the  lachrymal  ducts  or  into  the  Eustachian  tubes ;  (c)  into  the 
cesophagus ;  and  (d)  to  other  mucous  membranes,  or  to  wounds  or  excoria- 
tions. 

Laryngeal  diphtheria. — The  formation  of  false  membrane  in  the  larynx 
gives  rise  to  one  of  the  most  common  as  well  as  one  of  the  most  fatal 
varieties  of  the  disease.  It  occurs  mainly,  though  not  exclusively,  among 
children.  The  laryngeal  affection  is  either  primary  (diphtheritic  or  mem- 
branous croup),  in  which  case  laryngeal  symptoms  predominate  from  the 
outset ;  or  more  commonly  it  is  due  to  extension  of  the  local  inflammation 
from  the  fauces  or  pharynx,  such  extension  generally  taking  place  between 
the  third  and  sixth  days  of  the  disease.  The  symptoms  are  characteristic 
and  unmistakable.  Some  hoarseness  of  voice  and  a  dry,  short,  sometimes 
metallic,  cough  are  among  the  earliest  indications.  Very  soon  attacks  of 
paroxysmal  dyspnoea  supervene  with  noisy  stridor,  especially  during  in- 
spiration. At  first  these  attacks  may  be  separated  by  considerable  inter- 
vals, during  which  the  child  exhibits  but  few  signs  of  distress,  and  in 
favourable  cases  the  laryngeal  symptoms  often  subside  after  a  few 
paroxysms  of  moderate  severity.  In  bad  cases  the  attacks  increase  in 
frequency  and  violence,  and  before  long  the  dyspnoea  becomes  continuous. 
Huskiness  gives  place  to  complete  aphonia,  the  face  and  extremities 
become  livid,  and  the  pulse  more  frequent  and  small.  There  is  extreme 
restlessness,  and  a  look  of  intense  anxiety  on  the  face  as  the  child  clutches 
wildly  at  its  throat  or  at  anything  within  reach  in  its  vain  attempts  to  get 
breath.  The  respiratory  movements  are  violent,  though  ineffectual ;  there 
is  marked  inspiratory  recession  at  the  epigastrium  and  above  the  clavicles. 
As  suffocation  advances  cyanosis  deepens,  the  face  and  extremities  become 
cold  and  clammy,  and  the  patient  gradually  passes  into  a  semi-comatose 
condition,  death  eventually  taking  place  by  asphyxia.  The  suffocative 
phenomena  in  this  form  of  the  disease  are  mainly  due  to  the  occlusion 
of  the  larynx  by  false  membrane,  and  may  be  temporarily  relieved  by  the 
expulsion  of  pieces  of  membrane  or  plugs  of  mucus  through  the  mouth. 

In  children  death  sometimes  occurs  within  a  few  hours  of  the  onset  of 
laryngeal  symptoms,  not  often  later  than  the  fifth  day.  In  adults  the 
course  of  the  disease  is  usually  less  acute.  The  onset  of  inspiratory 
dyspnoea  is  gradual,  and  the  paroxysms  when  they  occur  are  far  less  dis- 
tressing. Prostration  is  usually  well  marked,  but  dyspnoea  may  not  become 
obtrusive  until  the  membrane  has  reached  the  smaller  bronchial  tubes. 

In  cases  where  laryngeal  dyspnoea  has  been  relieved  by  tracheotomy, 
pulmonary  dyspnoea  may  ensue  from  several  causes,  of  which  the  chief 
are — (1)  Extension  of  membrane  downwards  into  the  smaller  bronchi,  a 
condition  frequently  associated  with-  broncho-pneumonia ;  (2)  congestion 
of  the  lungs ;  (3)  collapse  of  the  lungs ;  (4)  acute  insufflation  of  the  anterior 
part  of  the  lungs.  The  auscultatory  signs  in  laryngeal  cases  are  very 
variable.  Loud  laryngeal  stridor  is  often  audible  over  the  lungs  during  the 
paroxysms,  the  vesicular  sound  being  very  faint  or  entirely  obscured.     The 


DIPHTHERIA.  207 

extension  of  membrane  into  the  bronchi  may  be  very  difficult  to  recognise 
during  life.  In  protracted  cases  there  may  be  signs  of  broncho-pneumonia, 
but  more  often  increasing  lividity  and  asthenia,  excessive  inspiratory  reces- 
sion of  the  lower  thoracic  zone,  with  diminished  or  suppressed  auscultatory 
phenomena,  afford  the  only  indications.  Subcutaneous  emphysema  of  the 
neck  and  chest  is  occasionally  met  with. 

Nasal  diphtheria. — The  nose  is  usually  invaded  by  extension  from  the 
pharynx,  but  is  also  occasionally  the  seat  of  the  primary  infection.  The 
prominent  symptoms  are  blocking  of  the  nares,  and  a  thick  muco-purulent 
or  thin  sanious  irritating  discharge  from  the  nostrils.  Eespiration  is  usually 
embarrassed,  and  often  snuffling.  Epistaxis  occurs  frequently,  and  may  be 
severe.  False  membrane  may  be  visible  within  the  nostrils,  but  is  more 
often  limited  to  the  back  of  the  nasal  cavities.  Very  exceptionally 
it  spreads  from  the  nostril  over  the  excoriated  upper  lip.  Glandular 
swelling  is  usually  well  marked.  The  inflammation  may  extend  into  the 
lachrymal  ducts,  and  infection  may  possibly  reach  the  conjunctivas  through 
this  channel.  There  is  often  associated  faucial  or  pharyngeal  disease. 
The  constitutional  symptoms  are  usually  severe.  The  frequency  of  nasal 
complications  in  malignant  diphtheria  has  already  been  alluded  to. 

Eeference  may  here  be  made  to  a  remarkable  affection  described  by 
American  observers.  It  consists  of  a  membranous  or  fibrinous  rhinitis, 
occurring  usually  in  children,  and  running  a  benign  course  with  little  or  no 
constitutional  disturbance.  The  nares  are  occupied  by  thick  membranes, 
which  rarely  extend  beyond  the  nose ;  and  a  large  majority  of  the  cases 
examined  yield  the  Klebs-Iojffler  bacillus.  Infection  of  other  children  in 
the  same  family  is  rare  Otitis  media  may  be  caused  by  extension  along 
the  Eustachian  tubes,  and  rarely  the  external  auditory  meatus  becomes 
invaded  through  a  ruptured  tympanic  membrane. 

(Esophageal  diphtheria.  —  The  spread  of  false  membrane  along  the 
oesophagus,  and  even  into  the  stomach,  is  seldom  recognised  during  life. 
It  is  altogether  of  rare  occurrence,  and  does  not  give  rise  to  any  special 
symptoms. 

Irregular  diphtheria. — External  wounds  and  abrasions  may  become 
secondarily  affected  in  persons  suffering  from  diphtheria.  But  cases  occur, 
on  the  other  hand,  in  which  a  wound  is  the  site  of  the  primary  disease, 
which  is  followed  in  due  course  by  general  infection.  In  rare  instances 
the  primary  lesion  is  situated  on  the  female  genital  organs,  or  about  the 
anus.  It  should  be  noted  in  this  connection  that  pseudo -membranous 
inflammation  of  wounds  and  ulcerated  surfaces  may  also  be  due  to 
streptococcus  infection.  A  granulating  wound  is  very  seldom  affected  by 
the  Bacillus  diphtherias,  and  though  the  tracheotomy  wound  may  become 
foul,  true  diphtheritic  membrane  is  very  rarely  found  upon  it. 

The  term  latent  diphtheria  has  been  applied  to  cases  in  which  faucial  or 
pharyngeal  inflammation,  due  to  the  bacillus  diphtherias,  is  not  accom- 
panied by  pellicular  exudation,  and  to  cases  of  nasal  and  laryngeal 
diphtheria  in  which  an  exact  diagnosis  is  not  arrived  at. 

Prolonged  form  of  diphtheria. — Cases  have  been  recorded  by  several 
observers  in  which  diphtheritic  membrane  continually  re-formed  for  many 
weeks,  and  even  months.  The  mucous  membrane  of  the  nose  appears 
to  be  specially  susceptible  to  this  form  of  the  disease.  Death  sometimes 
occurs,  chiefly  from  laryngeal  complications. 

Protection. — Although  an  attack  of  diphtheria  does  not  protect  against 
recurrence  of  the  disease,  the  writer  is  inclined  to  agree  with  those  wdio 


208  GENERAL  DISEASES. 

hold  that  one  attack  confers  some  degree  of  protection.  As  a  rule,  second 
attacks  are  not  so  severe  and  dangerous.  To  this  rule,  however,  there  are 
exceptions. 

Relapses. — Though  recrudescence  of  the  sore  throat  is  not  uncommon, 
true  relapses — supervening  before  the  patient  has  completely  recovered 
from  the  effects  of  the  primary  attacks — are  comparatively  rare.  Goodall 
and  Washbourn  met  with  them  in  16  out  of  1071  consecutive  cases  of 
diphtheria  admitted  into  the  Eastern  Hospital. 

Analysis  of  symptoms. — One  or  two  features  of  the  disease  which 
have  already  been  incidentally  alluded  to  require  somewhat  fuller  con- 
sideration. The  temperature  is  always  irregular  and  rarely  high,  except 
occasionally  at  the  onset.  It  is  in  no  way  a  characteristic  feature 
of  the  disease,  and  does  not  afford  reliable  indications  of  the  severity  of 
the  case.  While  it  may  never  rise  above  the  normal  in  a  malignant  case, 
a  comparatively  mild  uncomplicated  attack  may  be  ushered  in  by  a 
temperature  of  104°  or  105°  F.  Unusually  high  temperatures  occasionally 
accompany  laryngeal  and  pulmonary  complications. 

The  enfeeblement  of  the  heart  and  circulation,  which  is  always  met 
with  in  diphtheria,  is  part  of  the  rapid  general  bodily  exhaustion  which 
characterises  the  disease.  The  pulse  is  frequent,  of  low  tension,  and  may 
present  irregularities  of  force  and  rhythm,  which  are  not  necessarily  of 
serious  import.  The  heart  sounds  are  weak,  and  the  first  sound  often  short. 
In  rare  instances  there  is  extreme  slowness  of  pulse,  often  associated  with 
anuria  and  vomiting  ;  these  cases  are  almost  invariably  fatal. 

The  urine  contains  albumin  in  so  many  cases  that  this  should  be 
looked  upon  as  a  symptom  rather  than  a  complication  of  the  disease.  It 
probably  occurs  in  from  one-half  to  three-quarters  of  all  cases.  Albumin 
very  seldom  makes  its  first  appearance  after  the  tenth  day  of  the  disease. 
It  may  be  present  on  the  first  day,  but  is  more  often  found  on  the  third 
or  fourth.  The  quantity  varies  considerably  in  different  cases,  and  often 
in  the  same  case  from  day  to  day.  Speaking  generally,  the  amount  of 
albumin  is  not  a  trustworthy  prognostic  sign,  though  it  as  a  rule  appears 
earlier,  and  is  more  copious  and  persistent  in  a  severe  case  than  in  a  mild 
one.  It  should  be  remembered,  however,  that  some  fatal  cases  have  never 
had  albuminuria,  and  conversely,  that  a  highly  albuminous  urine  is  not 
a  bar  to  recovery.  (Edema  is  extremely  rare.  In  the  large  majority 
of  cases,  the  albuminuria  completely  disappears  within  a  few  days  or 
weeks.  The  microscopical  examination  of  the  urine  is  often  negative 
in  its  results ;  occasionally  a  few  hyaline  casts  or  renal  cells  may  be 
detected. 

Vomiting,  especially  repeated  vomiting,  is,  in  the  writer's  experience, 
an  almost  invariably  unfavourable  symptom,  whether  it  occurs  during  the 
height  of  the  disease,  in  association  with  anuria,  or  heart  failure,  or  during 
the  cardio-pulmonary  crisis  of  a  multiple  neuritis. 

Complications  and  sequelae. — Heart  failure  may  occur  at  any  stage 
of  the  acute  disease,  or  at  a  later  period  in  association  with  other  paralyses. 
More  rarely  it  takes  place  during  convalescence  from  the  primary  disease. 
Early  or  primary  cardiac  failure  is  generally  associated  with  varying 
degrees  of  fatty  degeneration  of  the  myocardium,  apparently  the  result  of 
a  direct  action  of  the  poison  on  the  heart  itself.  It  is  to  be  distinguished, 
clinically  at  least,  from  the  feebleness  of  the  circulation  which  occurs  in 
most  cases  of  diphtheria  as  part  of  the  general  bodily  prostration.  When 
cardiac  failure  is  gradual,  the  indications  are  usually  definite.  .  The  pulse 


DIPHTHERIA.  209 

rapidly  loses  strength,  and  the  neart  sounds,  the  first  especially,  become 
very  feeble  or  inaudible.  The  frequency  of  the  pulse  may  be  increased  or 
diminished,  or  there  may  be  marked  irregularity.  Cardiac  distress  and 
dyspnoea  are  often  experienced,  particularly  by  older  patients.  Extreme 
pallor  of  the  face  and  profound  prostration  are  usually  striking  symptoms. 
The  body  temperature  falls  continuously,  and  the  extremities  quickly 
grow  cold  and  moist.  Consciousness  is  retained  to  the  end,  which  may 
be  delayed  for  several  days.  In  some  cases,  fatal  syncope  takes  place 
absolutely  suddenly,  without  warning  of  any  kind ;  but  more  usually  life 
is  prolonged  for  some  hours.  Heart  failure,  occurring  in  the  later  stages 
of  the  disease,  will  be  dealt  with  under  the  head  of  paralysis. 

Lobular  'pneumonia  is  a  frequent  and  very  grave  complication  of  diph- 
theria of  the  air  passages.  Its  occurrence  is  usually  attended  by  rise  of 
temperature, — sometimes  to  a  great  height, — increased  rapidity  of  breathing, 
and  at  times  by  signs  of  patchy  consolidation  of  the  lungs. 

Paralysis. — The  frequency  of  this  sequela  has  been  variously  stated 
at  from  10  to  25  per  cent,  of  the  cases  which  recover  from  the  primary 
disease.  The  period  of  onset  is  uncertain.  Not  infrequently  a  careful 
examination  will  reveal  sluggish  action  of  the  pupils,  or  loss  of  power  of 
accommodation  for  near  objects,  even  before  the  beginning  of  convalescence 
after  the  primary  disease.  More  often,  however,  there  is  a  varying  interval 
between  the  cessation  of  the  primary  attack  and  the  recognition  of  the 
signs  of  paralysis. 

According  to  some  observers,  the  liability  to  paralysis  appears  to 
diminish  somewhat  with  age,  but  others  hold  the  contrary  opinion. 
The  comparative  infrequency  of  paralysis  after  laryngeal  diphtheria  is 
doubtless  in  part  clue  to  the  high  fatality  of  this  form  of  the  disease. 
The  degree  of  paralysis  does  not  appear  to  be  in  any  way  related  to  the 
severity  of  the  primary  disease.  Paralytic  symptoms  are  apt  to  develop 
earlier  after  a  severe  attack ;  but  some  of  the  worst  cases  are  met  with 
after  mild  attacks  of  the  primary  disease.  Occasionally  the  appearance 
of  paralysis  is  the  first  indication  of  a  previous  attack  of  diphtheria. 
The  symptoms  necessarily  vary  widely,  according  to  the  nerves  affected. 

The  onset  is  for  the  most  part  gradual,  and  the  paralysis  at  first  limited 
in  distribution.  It  may  remain  more  or  less  localised  throughout  the 
attack,  or  become  generalised. 

Paralysis  of  the  palate  is  very  common,  and  usually  the  earliest  to 
appear.  It  either  occurs  as  a  local  effect  of  the  inflammatory  changes  of 
the  primary  disease  on  the  muscles  and  nerves  of  the  palate,  or  develops  as 
a  consequence  of  the  parenchymatous  degeneration  of  the  peripheral  nerves, 
which  is  the  chief  cause  of  the  paralytic  phenomena  of  diphtheria.  On 
inspection,  the  velum  palati  is  seen  to  hang  motionless  during  respiration 
and  phonation,  and  is  insensitive  to  touch.  The  paralysis  may  be  unequally 
developed  on  the  two  sides,  and  in  very  rare  instances  is  unilateral. 
Paralysis  of  the  palate  is  characterised  by  a  peculiar  nasal  quality  of  the 
voice,  and  a  tendency  to  the  regurgitation  of  fluids  through  the  nose  during 
the  act  of  swallowing,  owing  to  the  impossibility  of  shutting  off  the 
posterior  nares  from  the  general  cavity  of  the  pharynx.  Associated 
difficulty  in  swallowing  from  paralysis  of  the  pharynx  is  frequent.  In 
many  cases  the  paralytic  symptoms  do  not  proceed  beyond  this,  and  the 
affected  parts  recover  completely  after  a  varying  interval.  Frequently, 
however,  other  parts  of  the  body  become  affected.  Paralysis  of  the  ocular 
muscles  is  not  uncommon.  Affection  of  the  ciliary  muscle  entails  loss  of 
vol.  1. — 14 


210  GENERAL  DISEASES. 

power  of  accommodation,  for  near  objects  especially,  and  a  sluggish  reaction 
of  the  pupils  to  light.  Internal  squint  is  comparatively  frequent,  ptosis 
much  rarer.  The  writer  has  seen  one  patient  with  complete  ophthalmoplegia 
of  both  eyes,  but  such  cases  are  altogether  exceptional.  Concentric  con- 
traction of  the  fields  of  vision  and  temporary  amaurosis  have  also  been 
described,  but  changes  in  the  fundus  oculi  do  not  take  place.  Deafness 
and  loss  of  taste  and  smell  are  very  rare  manifestations.  Headache  does 
not  occur.     Facial  paralysis  occurs  rarely,  and  is  ill-defined. 

Paralysis  of  the  limbs  is  not  infrequently  the  first  symptom  to  draw 
attention  to  the  condition  of  the  patient,  and  is  met  with  in  every  degree 
of  severity.  Tingling  and  "  pins  and  needles "  sensations  may  be  com- 
plained of  by  older  children  and  adults  in  the  parts  about  to  become 
paralysed.  The  affection  of  the  limbs  is  usually  bilateral,  and  the  legs 
commonly  suffer  before  the  arms.  There  is  nearly  always  more  or  less 
ataxia  and  unsteadiness  of  gait,  very  marked  indeed  in  some  cases.  As 
the  paralysis  increases,  the  limbs  gradually  become  quite  useless,  and 
the  affected  muscles  waste  visibly.  Muscular  power,  however,  is  rarely 
completely  abolished.  Faradic  irritability  is  gradually  extinguished,  but 
the  galvanic  reactions  are  usually  retained.  Disorders  of  sensation  are  not 
uncommon,  and  occasionally  some  anaesthesia  of  the  extremities  can  be 
made  out.  The  condition  of  the  reflexes  is  variable.  The  plantar  and 
cremasteric  reflexes,  though  sometimes  absent,  are  for  the  most  part 
present.  The  knee-jerks  are  lost ;  but  before  their  extinction  a  period  of 
exaggeration  is  by  no  means  rare.  In  some  instances  an  increase  of  tendon 
reflexes  in  the  upper  limbs  has  been  noticed.  Absence  of  knee-jerks, 
without  palsy,  may  also  be  met  with  either  during  or  after  an  attack  of 
diphtheria.  Eecovery  of  power  and  of  normal  electrical  reactions  is 
always  complete,  but  may  be  delayed  for  several  months.  In  like  manner, 
the  date  of  reappearance  of  the  knee-jerk  varies  within  wide  limits. 

In  cases  where  the  paralysis  becomes  widespread,  the  muscles  of  the 
back  and  neck  may  be  affected.  It  is  especially  in  this  class  of  case  that 
paralysis  of  the  larynx  and  of  the  muscles  of  respiration  are  prone  to 
develop.  The  cardio-pulmonary  seizures  which  constitute  the  gravest 
danger  of  diphtheritic  multiple  paralysis  are,  in  the  writer's  experience, 
usually  confined  to  cases  of  this  type.  The  general  symptoms  and  appear- 
ance of  these  patients  are  sufficiently  definite  to  merit  description.  They 
present  few,  if  any,  signs  of  distress  as  they  lie  more  or  less  helpless  in 
bed,  for  the  most  part  on  their  back.  The  breathing  is  quiet,  and  at  times 
rather  slow ;  it  may  be  sighing  in  character,  but  is  rarely  laboured.  The 
face  is  pale,  at  times  a  trifle  dusky,  and  one  is  forcibly  struck  by  the  list- 
less or  apathetic  condition  of  the  patients.  They  instinctively  shun  any 
kind  of  exertion.  They  are  with  difficulty  induced  to  speak,  and  only 
answer  in  a  whisper,  or  b.y  a  nod  of  the  head.  It  is  the  rarest  event 
to  hear  one  cry.  They  are  generally  fairly  well  nourished,  and  take  food 
readily ;  but  swallowing  is  often  accompanied  by  a  good  deal  of  spluttering 
and  regurgitation  through  the  nose.  There  is  almost  invariably  paralysis 
of  the  palate  and  pharynx.  Laryngeal  paralysis  is  often  present.  The 
extremities  are  always  paralysed,  and  weakness  of  the  muscles  of  the  back 
and  neck  is  frequently  associated.  The  heart  is  usually  acting  weakly,  and 
the  movements  of  respiration  are  feeble.  The  bowels  act  sluggishly ;  but 
further  'than  this,  disordered  action  of  the  sphincters  is  very  rare. 

Evidence  of  paralysis  of  the  larynx  is  to  be  found  in  huskiness  or 
aphonia,  and  in  a  characteristic  alteration  of  the  cough,  which  becomes 


DIPHTHERIA.  211 

non-explosive  and  ineffectual;  this  change  is  sensibly  accentuated  where 
paralysis  of  the  diaphragm  is  superadded.  Swallowing,  especially  of 
liquids,  sets  up  violent  and  exhausting  attacks  of  coughing  and  choking, 
particularly  when  the  mucous  membrane  is  insensitive,  and  the  lower 
portion  of  the  pharynx  and  the  muscles  closing  the  upper  orifice  of  the 
larynx  are  also  paralysed.  Mucus  tends  to  accumulate  in  the  lungs,  and 
broncho  -pneumonia  may  result  from  the  passage  of  food  particles  into  the 
bronchi. 

Paralysis  of  the  intercostal  muscles  is  comparatively  rare,  and  may 
be  unilateral.  The  respiratory  movements  of  the  affected  region  are 
diminished  or  lost;  and  if  the  paralysis  is  prolonged,  collapse  of  the 
subjacent  lung  is  apt  to  occur,  and  may  give  rise  to  definite  physical  signs. 
Paralysis  of  the  diaphragm  is  of  more  common  occurrence,  and  of  serious 
import  owing  to  its  frequent  association  with  grave  symptoms  of  heart 
failure  (cardio-pulmonary  seizures  or  crises).  Diaphragmatic  paralysis  was 
met  with  by  the  writer  in  twenty-eight  out  of  sixty-four  consecutive  cases 
of  diphtheritic  paralysis  admitted  to  the  North-Eastern  Children's  Hospital. 
In  seventeen  of  these  cardiac  crises  occurred.  The  affection  of  the 
diaphragm  may  come  on  insidiously,  and  without  obvious  symptoms,  or 
develop  quite  suddenly  as  part  of  a  cardio-puhnonary  crisis. 

The  cardio-pulmonary  seizures  are  alarmingly  sudden  in  onset.  The 
dominant  symptoms  are  those  of  asphyxia,  with  failure  of  the  heart. 
Vomiting  is  a  common  initial  symptom.  There  is  urgent  dyspnoea,  with 
cyanosis  or  dusky  pallor  and  extreme  restlessness.  Inspiration  is  sighing 
or  gasping,  and  expiration  feeble.  The  surface  and  extremities  grow  cold 
and  clammy.  Mucus  accumulates  rapidly  in  the  air  passages,  and  the 
lungs  become  oeclematous.  When  the  diaphragm  is  paralysed,  there  is 
usually  extensive  collapse  of  the  pulmonary  bases,  which  may  give  rise  to 
physical  signs.  The  pulse  becomes  very  frequent,  and  arterial  tension  very 
low.  Irregularity  is  often  present.  The  seizures  vary  much  in  duration 
and  severity.  Eecovery  is  rare  (five  cases  out  of  twenty-two  in  the  series 
quoted  above). 

Cerebral  complications. — Paralysis  of  a  hemiplegic  type  is  occasionally 
met  with  in  diphtheria.  It  may  be  due  to  cerebral  hsemorrhage,  or  to 
thrombosis,  or  embolism  of  the  cerebral  vessels.  The  onset  may  be  con- 
vulsive. 

Renal  complications. — Suppression  of  urine  is  a  somewhat  rare  and 
almost  invariably  fatal  complication  of  diphtheria.  Its  chief  features  are 
well  illustrated  by  the  following  case : — "  A  girl  set.  3  years  was  admitted 
to  hospital  under  the  writer's  care  on  31st  March,  on  the  seventh  day  of 
the  disease.  The  right  tonsil  was  partly  covered  by  membrane.  The  child 
was  unusually  pale,  and  very  quiet  and  drowsy.  The  pulse  was  regular 
and  small,  48  to  the  minute.  There  was  frequent  and  uncontrollable 
vomiting.  During  the  first  twenty-four  hours  she  passed  a  few  drachms 
of  urine  loaded  with  albumin ;  after  this  there  was  total  suppression  till 
death  on  4th  April.  There  was  no  oedema.  The  pulse  ranged  between  40 
and  48.  The  vomiting  subsided  after  the  first  forty-eight  hours.  The 
heart  grew  steadily  weaker.  Death  was  ushered  in  by  a  general  con- 
vulsion. The  kidneys  were  large  and  congested,  and  exhibited,  under  the 
microscope,  well-marked  signs  of  early  tubular  nephritis.  A  sister  had 
died  a  few  days  before,  also  from  anuria."  In  some  cases  the  pulse  is 
frequent  and  irregular. 

Although    in    most   cases   albuminuria   is   symptomatic   and   rapidly 


212  GENERAL  DISEASES. 

disappears  with  convalescence,  the  condition  of  the  urine  is  sometimes 
indicative  of  nephritis.  The  total  quantity  is  small,  and  it  contains  a 
large  amount  of  albumin  and  numerous  epithelial  or,  more  rarely,  blood 
casts.  Dropsy,  however,  is  extremely  rare.  This  complication  is  always  a 
grave  one.  It  may  pass  into  complete  suppression,  and  there  is  reason  to 
believe  that  it  is  occasionally  the  starting-point  of  chronic  renal  trouble. 

Diagnosis. — It  may  be  laid  down  as  a  guiding  rule,  that  in  all — and 
particularly  in  doubtful — cases  of  diphtheria  a  bacteriological  examination 
should,  if  possible,  be  made  at  the  earliest  opportunity.  In  any  case  it  is 
a  good  rule  to  "regard  as  suspicious  all  forms  of  throat  affections  in 
children,  and  carry  out  measures  of  isolation  and  disinfection  "  (Osier). 

Faucial  diphtheria — In  cases  where  diphtheria  of  the  fauces  is  un- 
attended by  membranous  exudation,  the  appearances  may  be  indistinguish- 
able from  those  of  simple  or  catarrhal  sore-throat,  and  a  bacteriological 
examination  alone  can  determine  the  true  nature  of  the  case.  The  presence 
of  albuminuria  in  such  cases  is  always  suspicious,  and  the  association  of 
laryngeal  stridor  or  of  a  sanious  nasal  discharge  goes  far  to  establish  the 
diagnosis  of  diphtheria. 

The  distinction  between  diphtheria — at  an  early  stage — and  follicular 
tonsillitis  may  present  considerable  difficulty.  This  is  especially  the  case 
where  the  yellow  follicidar  contents  escape  on  to  the  surface  of  the  tonsils  so 
as  to  form  small  patches,  or  where  diphtheria  is  at  first  localised  in  and 
around  the  tonsillar  crypts.  The  membrane  in  the  diphtheritic  cases 
generally  spreads  rapidly  to  contiguous  parts,  and  the  occurrence  of  other 
signs  of  diphtheria  will  often  help  the  diagnosis.  Albuminuria  is  uncommon 
in  non-diphtheritic  inflammations  of  the  fauces,  and  does  not  occur  in 
simple  follicular  tonsillitis.  In  this  affection,  too,  the  phenomena  of  onset 
are  usually  more  definite,  and  labial  herpes  is  not  uncommon.  Whitish 
patches,  not  unlike  the  false  membrane  of  diphtheria,  may  be  caused  by 
vesicants  and  escharotics,  and  by  closely  set  herpes  vesicles.  The  history 
of  the  case,  and  possibly  the  presence  of  herpetic  vesicles  on  the  lips  or  face, 
will  reveal  the  true  nature  of  the  faucial  affection. 

The  milk-white  spots  of  thrush  (oidium  albicans^)  may  run  together  to 
form  patches  of  considerable  extent.  Their  colour  is  whiter  than  that  of 
diphtheritic  false  membrane,  and  the  microscopical  appearance  of  the 
fungus  is  unmistakable.  Thrush  does  not  give  rise  to  any  general 
symptoms,  and  is  usually  met  with  in  marasmic  children  or  in  adults 
suffering  from  chronic  wasting  diseases. 

In  the  early  stages  of  scarlet  fever,  in  the  absence  of  rash,  the 
diagnosis  from  diphtheria  may  be  attended  with  much  difficulty,  both  in 
cases  where  there  is  exudation  on  the  fauces  and  where  it  is  absent. 
Goodall  and  Washbourn  lay  stress  on  the  following  points :  "  In  scarlet 
fever  the  febrile  symptoms  are  more  pronounced  than  in  diphtheria,  so 
that  a  high  temperature,  a  very  frequent  pulse,  and  delirium  are  in  favour 
of  this  disease  rather  than  diphtheria.  Membranous  sore-throat  with 
little  or  no  pyrexia  is  almost  certainly  diphtheria.  Vomiting  is  much 
more  constantly  a  prodromal  symptom  of  scarlet  fever  than  diphtheria, 
Much  oedema  of  the  parts  underlying  the  membrane  is  in  favour  of  scarlet 
fever,  so  also  is  a  very  red  hue  of  the  fauces. 

"  In  cases  where  the  exudation  is  pultaceous  and  not  distinctly 
membranous,  scarlet  fever  must  be  suspected,  if  the  febrile  and  other 
symptoms  that  have  just  been  mentioned  are  marked.  The  '  strawberry ' 
tongue  is  seen  more  often  in  scarlet  fever  than  in  diphtheria,  in  which 


DIPHTHERIA  213 

disease,  as  in  others  also,  it  is  occasionally  met  with ;  mucn  more  character- 
istic of  scarlet  fever  is  the  '  peeling  tongue.' 

"  The  occurrence  of  ulceration  (unless  it  be  very  superficial)  and  gan- 
grene of  the  fauces  is  exceptional  in  diphtheria.  ...  In  all  cases,  any 
history  of  exposure  to  the  specific  infection  of  scarlet  fever  or  diphtheria, 
as  the  case  may  be,  is  important." 

The  occurrence  of  paralysis  after  an  attack  of  sore-throat  may  be 
looked  upon  as  conclusive  evidence  of  its  diphtheritic  nature.  It  must 
suffice  to  mention  that  syphilitic  and  tuberculous  affections  of  the  fauces 
may  superficially  resemble  diphtheria,  and  to  recall  the  rare  occurrence  of 
membranous  affections  of  the  same  region  in  enteric  fever  and  other  acute 
specific  diseases. 

Laryngeal  diphtheria. — In  the  absence  of  signs  of  diphtheria  in 
the  fauces  or  elsewhere,  this  form  of  the  disease  in  children  may  be 
impossible  to  distinguish  from  simple  or  catarrhal  laryngitis  during  life. 
A  case  of  simple  laryngitis  usually  improves  rapidly  when  placed  under 
favourable  conditions,  whereas  diphtheria  tends  to  grow  steadily  worse. 
The  catarrhal  croup  which  sometimes  accompanies  the  onset  of  measles, 
usually  subsides  with  the  appearance  of  the  rash.  "  The  respiratory 
stridor  in  some  cases  of  catarrhal  croup  is  excessive,  and  reaches  a  height 
of  noisiness  which  is  uncommon  in  diphtheritic  croup  "  (Gee). 

In  adults  the  diseases  most  likely  to  simulate  diphtheria  are  various 
forms  of  laryngeal  ulceration,  of  growths,  oedema  of  the  glottis,  and  paralysis 
of  the  abductors  of  the  vocal  cords  of  sudden  onset.  A  remarkable 
example  of  the  latter  affection  came  recently  under  the  writer's  notice. 
The  patient,  a  young  man,  was  suddenly  seized  with  laryngeal  dyspnoea 
and  cyanosis,  which  rapidly  grew  worse  and  ended  fatally  within  a  few 
days,  without  any  other  symptoms  declaring  themselves.  It  was  most 
difficult  to  exclude  diphtheria  during  life. 

Prognosis. — The  fatality  of  the  disease  is  very  high,  ranging  in 
hospital  practice  (since  the  introduction  of  antitoxine  treatment),  from  18 
to  40  per  cent.  The  chief  prognostic  signs  have  already  been  mentioned  in 
the  preceding  pages,  and  need  only  be  recapitulated  here.  Among  the 
chief  indications  of  severity  are  dusky  pallor  and  extreme  prostration,  a 
large  extent  of  membrane,  feebleness  of  circulation,  with  frequent  or 
unduly  slow  pulse,  early  absence  of  knee-jerk,  highly  albuminous  or  scanty 
urine,  epistaxis  or  other  haemorrhages,  extensive  glandular  swelling  and 
brawny  induration  of  the  neck.  Repeated  vomiting  and  diarrhoea  are  both 
symptoms  of  ill  omen,  and  convulsions  are  nearly  always  of  the  gravest 
import.  The  occurrence  of  laryngeal  complications  is  most  unfavourable. 
Symptoms  of  cardiac  failure  may  develop  at  almost  any  period  of  the 
attack,  and  in  common  with  widespread  paralysis  may  arise  in  cases  which 
appeared  mild  at  the  outset. 

The  prognosis  in  cases  of  widespread  paralysis  is  always  serious  and 
very  grave  if  the  muscles  of  respiration  are  involved.  Recovery  from 
cardio-pulmonary  seizures  is  rare  {vide  supra,  p.  211).  Death  during  the 
course  of  the  primary  disease  is  usually  due  to  one  of  the  following  causes: — 
(1)  Suffocation  from  laryngeal  obstruction;  (2)  pulmonary  complications ; 
(3)  intense  toxaemia ;  (4)  suppression  of  urine,  with  or  without  con- 
vulsions ;  (5)  heart  failure.  Death  during  the  course  of  paralysis  is 
always  accompanied  by  symptoms  of  heart  failure.  In  most  cases  there  is 
associated  paralysis  of  the  muscles  of  respiration,  especially  the  diaphragm, 
with  post-mortem  signs  of  asphyxia.     Convalescence  is  often  tedious,  even 


2i4  GENERAL  DISEASES. 

after  a  mild  attack,  and  complete  recovery  may  be  delayed  for  several 
months,  especially  after  paralysis. 

Treatment. — It  will  be  convenient  to  consider  preventive  and 
remedial  measures  separately. 

Prophylaxis. — The  essential  points  to  be  attended  to  in  the  treatment 
of  every  case  of  diphtheria,  however  mild,  are  careful  isolation  and  dis- 
infection. In  families  or  schools  where  the  disease  has  broken  out,  every 
member  should  be  kept  under  close  observation,  and  suspected  cases  at 
once  isolated.  One  chief  danger  of  spread  is  due  to  the  non-recognition 
of  mild  (ambulatory)  cases.  Another  point  of  great  importance  is  to 
ensure  that  the  throat  is  entirely  free  of  diphtheria  bacilli  before  con- 
valescents are  sent  home.  There  is  abundant  evidence  to  show  that 
virulent  bacilli  may  persist  in  the  throat  for  weeks  or  even  months  after 
all  local  signs  of  disease  have  disappeared,  and  become  the  means  of  com- 
municating the  disease  to  others. 

The  sick-room  should  be  well  ventilated,  and  free  from  superfluous 
hangings  and  furniture.  All  discharges  from  the  patient  should  be 
carefully  disinfected.  Pieces  of  rag  should  be  used  instead  of  handker- 
chiefs, and  immediately  burned. 

Local  treatment  should  be  actively  employed  in  all  cases,  and  in 
such  a  way  as  to  avoid  mechanical  injury  of  the  tissues.  The  application 
may  be  made  either  with  a  swab  of  cotton-wool  or  in  the  form  of  spray, 
gargle,  or  by  irrigation.  In  infants  this  procedure  is  often  most  difficult 
and  trying  to  carry  out.  Gargles  of  permanganate  of  potash  or  chlorine 
water  may  be  employed  in  mild  cases.  Sprays  of  perchloride  of  mercury 
(1  in  1000  or  2000  parts  of  water)  or  carbolic  acid  (3  per  cent,  in  30  per 
cent,  alcohol  solution)  are  among  the  best.  They  should  be  used  every 
four  hours  in  mild  cases,  but  more  frequently  in  severe  ones.  Saturated 
solutions  of  boric  acid  and  of  bicarbonate  of  soda  are  also  useful.  Irriga- 
tion  with  solutions  of  boric  acid,  chlorine,  or  permanganate  of  potash  is 
highly  spoken  of,  especially  for  the  treatment  of  septic  conditions  of  the 
throat.  In  nasal  diphtheria  the  nostrils  should  be  kept  thoroughly 
cleansed  by  syringing  or  irrigating  with  dilute  disinfectant  solutions. 
If  signs  of  laryngeal  affection  occur,  a  steam  tent  should  be  arranged 
upon  the  bed.  Symptoms  of  croup  will  often  be  relieved  in  this  way. 
Much  relief  is  also  sometimes  given  by  a  hot  bath.  If  the  signs  of 
laryngeal  obstruction  increase  in  severity,  tracheotomy  or  intubation  should 
be  performed  without  delay,  especially  where  dyspnoea  is  urgent  and  the 
patient  is  becoming  cyanosed  or  drowsy.  The  prospects  of  success  are 
better  in  early  than  in  late  interference,  although  it  should  be  added  that 
it  is  never  too  late  to  operate.  Of  the  two  operations,  tracheotomy  is  to 
be  preferred.  In  all  cases  of  tracheotomy  it  is  desirable  that  the  after- 
treatment  should  be  carried  out  by  properly  trained  nurses. 

General  treatment. — The  patient  should  be  kept  in  bed  and  dis- 
turbed as  little  as  possible,  on  account  of  the  liability  to  heart  failure. 
The  strength  should  be  supported  by  careful  feeding  and  stimulants.  The 
diet  should  consist  mainly  of  milk,  with  small  quantities  of  beef-tea  and 
beef -juices.  Alcohol  should  be  given  at  the  first  indication  of  heart  failure, 
and  from  the  outset  if  the  constitutional  symptoms  are  severe.  Among 
drugs,  strychnine  is  perhaps  the  best.  It  may  be  given  alone,  or  in  com- 
bination with  iron.  In  the  treatment  of  heart  failure  strychnine  is  better 
than  digitalis,  which  is  of  doubtful  efficacy.  It  is  most  conveniently 
administered  hypodermically  in  doses  of  j-Jq  grain  at  intervals  of  three 


DIPHTHERIA.  215 

or  four  hours.  Drugs  are  of  very  little  use  in  the  treatment  of  repeated 
vomiting.  Food  by  the  mouth  may  be  withheld,  and  nutrient  enemata  or 
suppositories  substituted. 

The  treatment  of  paralysis  requires  rest  in  bed.  When  the  paralysis 
remains  limited  to  the  palate  or  ocular  muscles,  the  patient  may  be  allowed 
to  get  up  at  the  end  of  two  or  three  weeks.  In  cases  where  it  becomes 
widespread,  or  in  which  there  is  cardiac  irregularity,  prolonged  rest  is 
essential,  and  it  is  imperative  that  the  patient  should  avoid  every  kind 
of  exertion.  Difficulty  in  swallowing,  or  evidence  of  the  passage  of 
food  into  the  larynx,  should  at  once  be  met  by  giving  the  food  through 
an  oesophageal  or  nasal  tube.  The  latter  is  preferable  in  the  case  of  very 
young  children. 

The  treatment  of  the  late  cardio-pulmonary  seizures  is  almost  hopeless. 
Hypodermic  injections  of  strychnine  and  brandy  should  be  given,  and 
oxygen  inhalations  administered.  Artificial  respiration  often  causes  a 
temporary  improvement,  and  in  two  or  three  cases  under  the  writer's  care 
appeared  to  contribute  towards  recovery.  Favourable  results  have  also 
been  claimed  for  tincture  of  belladonna  given  in  full  doses.  Galvanism 
has  been  recommended  for  the  treatment  of  paralysis  of  the  diaphragm. 
Here  also  the  systematic  performance  of  artificial  respiration  at  intervals 
of  a  few  hours  is  worthy  of  trial,  with  the  object  of  preventing  collapse  of 
the  pulmonary  bases.  In  the  treatment  of  chronic  cases  of  paralysis  of 
the  limbs  and  trunk,  massage  and  galvano-faradism  are  useful  adjuncts. 

Antitoxine  treatment. — This  consists  in  the  subcutaneous  injection 
of  the  blood  serum  of  animals  rendered  artificially  immune  against  diph- 
theria. The  serum  used  is  that  of  horses  that  have  been  immunised  by 
repeated  injections  of  the  diphtheria  toxine  or  of  cultivations  of  the 
diphtheria  bacillus.  The  strength  of  a  serum  is  gauged  by  determining 
how  many  "  normal  units  "  a  certain  amount  contains.  A  ,r  normal  unit "  is 
ten  times  the  amount  of  serum  required  to  neutralise  ten  lethal  doses 
of  the  toxine  when  injected  into  a  guinea-pig  of  about  300  grms.  The 
serum  acts  in  two  ways  upon  animals :  in  minimal  doses  it  renders  the 
animal  immune  to  subsequent  injection  either  of  the  bacillus  itself  or  of 
its  toxine.  It  also  counteracts  the  toxine  when  mixed  with  it  before  injection 
into  an  animal.  It  is  injected,  therefore,  into  the  human  body,  in  cases  of 
diphtheria,  with  the  double  object  of  rendering  it  immune  to  the  further 
action  of  the  poison  and  of  counteracting  the  effects  of  the  poison  already 
absorbed.  The  most  careful  antiseptic  precautions  should  always  be  taken, 
and  the  syringe  sterilised  by  boiling  before  being  used.  The  results 
obtained  by  this  mode  of  treatment,  both  in  this  country  and  abroad,  have 
been  remarkably  uniform,  and  of  such  a  nature  as  to  fully  justify  the  belief 
that  antitoxic  serum  is  a  remedy  of  far  greater  value  in  the  treatment  of 
diphtheria  than  any  of  its  predecessors.  Its  effects  on  the  course  of  the 
disease  are  very  remarkable.1  The  general  mortality  is  reduced  by  about 
one-third,  and  the  mortality  in  tracheotomy  by  about  one-half.  Extension 
of  membrane  to  the  larynx  very  rarely  occurs  after  the  administration  of 
antitoxine,  and  there  is  also  a  very  sensible  diminution  in  the  number  of 
laryngeal  cases  which  require  tracheotomy.  Moreover,  the  remedy  is  of 
especial  value  in  the  very  classes  of  cases  which  under  any  other  treatment 
give  the  worst  results,  namely,  in  the  very  young,  and  in  the  laryngeal  form 
of  the  disease.     Thus  the  mortality  of  488  laryngeal  cases  treated  with 

1  For  fuller  information  on  this  subject,  the  reader  is  referred  to  the  "  Report  of  the  Com- 
mittee on  the  Antitoxine  of  Diphtheria,"  1898,  Trans.  Clin.  Soc.  London,  vol.  xxxi. 


2l6 


GENERAL  DISEASES. 


antitoxine  was  only  28'8  per  cent.,  whilst  of  197  cases  in  which  tracheotomy 
was  performed  nearly  60  per  cent,  recovered. 

Two  essential  conditions  to  success  are — (1)  To  commence  the  treatment 
at  an  early  stage  of  the  disease,  and  (2)  to  inject  a  sufficient  dose  of  anti- 
toxine. It  has  been  truly  said  that  "a  dose  of  2000  units  will  usually 
secure  a  result  on  the  first  day  which  50,000  will  not  effect  on  the  fourth." 
The  following  figures,  taken  from  the  report  of  medical  superintendents  of 
the  Metropolitan  Asylums  Board  for  1896,  quoted  below,  illustrate  the 
importance  of  early  treatment : — 


No.  of  Cases. 

Day  of  Disease 

on  which  Treatment 

was  begun. 

Mortality  per 
Cent. 

57 

406 

557 

579 

1165 

1st 

2nd 

3rd 

4th 

5  th  and  after 

5-2 
15-0 
21-9 

27-8 
31-7 

As  regards  dosage,  no  hard-and-fast  rules  can  be  laid  down.  Each  case 
must  be  treated  on  its  merits.  There  is  every  advantage  in  using  the 
strongest  serum  obtainable.  In  mild  or  moderately  severe  cases  coming 
under  observation  on  the  first  or  second  day  of  the  disease,  a  single  dose  of 
two  or  three  thousand  normal  units  may  suffice ;  in  severe  cases  larger 
doses  should  be  employed.  If  definite  signs  of  improvement  do  not  follow 
within  twelve  hours,  a  second  injection  should  be  given.  There  need  be  no 
hesitation  in  doing  this,  as  the  remedy  does  not  cause  any  material  harm. 
Opinions  are  still  divided  as  to  whether  it  is  better  to  push  the  remedy 
vigorously  during  the  first  forty-eight  hours,  or  to  give  it  in  smaller  doses 
over  a  longer  period.  The  writer's  personal  experience  is  decidedly  in 
favour  of  the  former  plan.  In  favourable  cases  there  is  a  marked  ameliora- 
tion both  in  the  local  and  general  symptoms.  There  is  a  rapid  diminution 
of  faucial  swelling  and  distress.  The  pulse  soon  improves,  and  other 
constitutional  symptoms  subside.  The  spread  of  the  false  membrane  is 
arrested,  and  it  separates  sooner  than  with  any  other  mode  of  treatment. 
Nasal  discharge,  when  present,  is  usually  much  diminished  or  disappears 
altogether.  In  laryngeal  cases  the  necessity  for  tracheotomy  is  often 
avoided,  and  the  results  after  tracheotomy  are  incomparably  better  than 
under  any  other  circumstances.  It  is  not  at  present  possible  to  form  a 
reliable  estimate  of  the  effect  of  antitoxine  on  the  occurrence  of  paralysis, 
partly  because  under  this  mode  of  treatment  a  larger  number  of  cases  recover 
from  the  primary  disease  in  which  paralysis  would  be  likely  to  supervene, 
partly  on  account  of  incomplete  knowledge  of  the  influence  of  dosage 
on  the  course  of  the  disease. 

The  antitoxine  treatment  should  be  adopted  in  every  case  of  diphtheria. 
As  regards  the  prophylactic  use  of  antitoxine,  it  should  be  borne  in  mind 
that  the  protection  afforded  is  not  of  long  duration.  Its  use  should  there- 
fore be  limited  to  cases  where  the  risk  of  infection  has  been  great.  In  a 
certain  proportion  of  cases,  and  with  some  specimens  of  serum  more  than 
others,  the  injection  of  antitoxine  is  followed  by  after-effects  or  complica- 
tions, which,  although  giving  rise  to  some  discomfort,  are  not  serious. 
They  are  rashes,  fever,  and  joint-pains,  and  usually  occur  from  one  to 


ERYSIPELAS.  217 

three  weeks  after  injection.  The  rashes  frequently  appear  first  at  or  near 
the  site  of  injection,  and  may  be  urticarial,  erythematous,  or  morbilliform. 
Desquamation  often  follows.  They  are  often  accompanied  by  fever  and 
some  general  disturbance.  Similar  rashes  may  follow  the  injection  of 
tetanus  antitoxine  and  tuberculin.  Joint-pains  are  much  less  frequent, 
but  may  be  severe,  and  are  generally  accompanied  by  fever  and  consider- 
able general  disturbance.  As  regards  the  alleged  injurious  effects  of 
antitoxine  on  the  kidneys,  causing  anuria  and  nephritis,  these  complica- 
tions are  not  more  frequent  in  cases  treated  with  antitoxine  than  in  those 
which  are  not. 

W.  PASTEUR. 


EEYSIPELAS. 

Syn.,  Fr.,  Erysipele ;  Ger.,  Erysipel ;  Rose. 

An  acute  infective  spreading  inflammation  of  the  skin,  due  to  a  strepto- 
coccus, and  associated  with  general  febrile  symptoms.  The  subcutaneous 
areolar  tissue  may  be  simultaneously  affected  (cellulitis).  Although  typic- 
ally an  infection  of  the  skin,  the  inflammation  may  also  affect  a  mucous 
membrane,  either  primarily  or  by  extension. 

Etiology  and.  pathology. — The  disease  is  widely  spread,  but  is 
more  frequent  in  temperate  and  cold  than  in  tropical  countries.  It  usually 
occurs  in  the  endemic  form,  but  may  assume  an  epidemic  type.  It 
is  especially  prevalent  during  the  spring  months  and  again  in  late 
autumn.  Chief  among  the  causes  which  favour  its  development  are  in- 
sanitary surroundings,  more  especially  overcrowding,  dirt,  and  defective 
drainage.  Improved  sanitation  and  the  adoption  of  aseptic  methods  in 
surgical  practice  have  led  to  a  very  material  diminution  in  the  number  of 
cases,  for  whereas  the  disease  was  formerly  the  scourge  of  hospitals,  it  is 
now  comparatively  rarely  to  be  found  there. 

The  virus  may  be  conveyed  through  the  air,  but  it  does  not  seem  to  act 
at  any  great  distance.  It  adheres  closely  to  clothes,  bedding,  furniture, 
etc.,  and  may  be  conveyed  by  a  third  person.  Women  are  said  to  be  more 
liable  to  the  disease  than  men.  Age  has  no  influence  on  its  incidence. 
Among  predisposing  causes,  the  more  important  are  chronic  alcoholism, 
faulty  hygienic  conditions,  debility  after  acute  or  chronic  diseases,  and 
diseases  of  the  liver  and  kidneys.  A  constitutional  predisposition  may 
exist,  and  is  sometimes  hereditary,  the  patient  usually  suffering  from 
repeated  attacks  of  the  disease.  A  wound,  abrasion,  or  sore  is  the  most 
important  predisposing  cause,  and  it  is  generally  held  that  the  disease  is 
invariably  caused  by  the  infection  of  a  wound.  Eecently  delivered  women 
are  particularly  susceptible  to  infection. 

The  determining  cause  of  erysipelas  is  a  streptococcus  (Strejrfococcus 
erysipelatis  of  Fehleisen)  which  is  held  by  most  to  be  identical  with  the 
Streptococcus  pyogenes:  its  peculiar  manifestations  in  this  disease  being 
attributed  to  a  certain  degree  of  virulence.  "  It  must  be  noted,  however, 
that  erysipelas  passes  from  patient  to  patient  as  erysipelas,  and  purulent 
conditions  due  to  streptococci  do  not  appear  liable  to  be  followed  by 
erysipelas.  On  the  other  hand,  the  connection  between  erysipelas  and 
puerperal  septicemia  is  well  established  clinically.  The  conditions  which 
produce   the    special    degree    of   virulence   in   the   streptococcus  for  the 


218  GENERAL  DISEASES. 

occurrence  of  erysipelas  are  not  yet  fully  known.  In  a  case  of  erysipelas 
the  streptococci  are  found  in  large  numbers  in  the  lymphatics  of  the  cutis 
and  underlying  tissues,  just  beyond  the  swollen  margin  of  the  inflammatory 
area.  As  the  inflammation  advances  they  gradually  die  out,  and  after  a 
time  their  extension  at  the  periphery  comes  to  an  end.  In  the  affected 
area  there  are  the  usual  changes  found  in  inflammation,  great  leucocytic 
emigration  and  serous  exudation  with  formation  of  fibrin  at  places,  but 
there  is  no  suppurative  liquefaction  of  the  tissues"  (Muir  and  Ritchie). 

The  streptococcus  of  erysipelas  can  be  grown  in  pure  culture  outside 
the  body,  and  may  reproduce  a  true  erysipelas  when  inoculated  into 
human  beings,  as  was  done  by  Fehleisen  in  his  endeavour  to  cure  certain 
forms  of  malignant  disease.  The  streptococcus  stains  with  the  ordinary 
aniline  dyes  and  by  Gram's  method.  The  chains  of  cocci  are  short  in  the 
human  body,  but  may  attain  a  considerable  length  in  artificial  cultivations. 

Morbid  anatomy. — The  post-mortem  appearances  in  an  uncom- 
plicated case  are  by  no  means  characteristic.  The  affected  skin  feels 
swollen,  hard,  and  inelastic ;  the  inflammatory  redness  disappears  after 
death.  Blebs,  desquamation,  and  effusion  into  the  subcutaneous  cellular 
tissue  are  usually  present.  The  internal  organs  are  congested,  and  the 
spleen  is  sometimes  much  enlarged.  There  is  usually  cloudy  swelling  of 
the  kidneys,  which  may  also  present  evidence  of  antecedent  chronic 
disease.  In  erysipelas  of  the  scalp,  subcutaneous  abscesses  are  not  un- 
common. When  death  has  been  due  to  septicaemia  or  pysemia,  the  visceral 
complications  of  these  infections  will  be  present.  There  may  be  septic 
inflammation  of  the  pleura,  pericardium,  and  occasionally  of  the  endo- 
cardium. Meningitis,  when  present,  is  probably  pysemic,  but  it  is  also 
said  to  arise  from  an  extension  inward  of  erysipelas  of  the  scalp.  Infarcts 
may  occur  in  the  lungs,  spleen,  and  kidneys,  and  there  may  be  the  evidence 
of  a  general  pysemic  infection.  Pneumonia  is  occasionally  met  with,  whilst 
hypostatic  congestion  of  the  lungs  is  common. 

Symptomatology. — The  incubation  period  is  usually  between  three 
and  seven  days.  In  Fehleisen's  inoculations  it  varied  between  fifteen  and 
sixty-one  hours.  Cutaneous  erysipela's  is  described  as  traumatic  or  idio- 
pathic, originating  in  the  former  case  in  connection  with  a  wound,  whilst  in 
the  latter  no  wound  or  abrasion  can  be  discovered.  The  distinction  between 
these  two  varieties  is  probably  purely  artificial ;  in  any  case  their  symptoms 
are  the  same.  Idiopathic  erysipelas  is  common  about  the  face  and  scalp. 
The  traumatic  variety  may  develop  wherever  there  is  a  wound,  or  the  equi- 
valent of  a  wound,  of  the  skin  or  of  a  mucous  membrane.  The  following 
description  applies  especially  to  erysipelas  of  the  head  and  face.  The 
invasion  is  usually  quite  sudden,  and  often  marked  by  a  rigor  or  vomit- 
ing. The  temperature  rises  rapidly,  sometimes  to  a  great  height,  and 
the  usual  symptoms  of  fever,  headache,  thirst,  anorexia,  etc.,  are  well 
marked.  The  chart  of  a  typical  case  is  shown  in  Fig.  35.  The  general 
symptoms  are  usually  in  direct  proportion  to  the  extent,  of  the  skin 
affection.  This  first  appears  simultaneously  with  or  within  a  few  hours 
of  invasion  as  a  sharply  defined  patch  of  redness,  either  in  relation  with 
a  pre-existing  wound  or  at  the  junction  of  a  mucous  membrane  and  the 
skin,  especially  the  corner  of  the  eye,  the  angle  of  the  mouth,  or  the 
external  auditory  meatus.  The  affected  skin  is  bright  red,  tense,  painful 
and  swollen,  and  pits  on  pressure.  The  inflammation  extends  in  all 
directions.  Its  spreading  margin  is  irregular,  sharply  defined,  and  slightly 
raised.     Swelling  of  the  subcutaneous  cellular  tissue  is  alwavs  marked,  and 


ER  YSIPELAS. 


219 


even  in  cases  of  moderate  severity  the  face  is  much  swollen,  the  eyes 
closed  up,  and  the  lines  of  expression  obliterated,  so  that  the  patient  is 
quite  unrecognisable.  Vesicles  form  over  the  inflamed  area,  and  may  run 
together  to  form  blebs  of  considerable  size.  These  ordinarily  contain  clear 
yellow  serum,  which  may  be  blood-stained  in  virulent  cases.  After  burst- 
ing, the  bullae  dry  up  and  leave  adherent  scabs.  The  cervical  glands  are 
always  enlarged  and  tender,  and  there  is  usually  some  general  swelling  of 
the  neck.  Suppuration  is  uncommon.  "  Definite  abscesses  occurring  in 
the  skin  or  subcutaneous  cellular  tissue  are  most  probably  the  result  of  a 
mixed  infection,  and  this  is  not  unlikely  to  be  the  case  when  they  occur, 
as  is  not  very  uncommon,  in  the  eyelids  "  (Watson  Cheyne).  The  febrile 
symptoms  usually  continue  unrelieved  as  long  as  the  skin  affection  is 
spreading.  After  a  few  days  the  inflammation  gradually  subsides,  and 
desquamation  of  the  cuticle  takes  place.  After  erysipelas  of  the  scalp 
there  may  be  a  temporary  complete  loss  of  the  hair.     Occasionally  the 


November 


December 


Fig.  35. — Temperature  in  erysipelas. 

inflammation  spreads  from  the  head  over  the  trunk  and  limbs  in  succes- 
sion. In  this  more  chronic  form  of  the  disease  (E.  migrans  vel  ambulans), 
which  occurs  more  often  in  young  children,  the  temperature  is  very 
irregular.  Slight  delirium  at  night  is  not  uncommon,  even  in  mild  cases. 
In  severe  cases  and  in  debilitated  individuals,  it  is  often  a  very  prominent 
symptom.  The  constitutional  disturbance  varies  much.  It  is  usually 
slight  in  uncomplicated  cases,  but  the  gravest  symptoms  may  supervene 
in  old  and  debilitated  persons,  and  in  the  subjects  of  chronic  alcoholism. 
In  some  drunkards  the  delirium  assumes  a  low  muttering  type,  the  tongue 
becomes  dry,  the  pulse  fails,  and  death  is  ushered  in  by  deepening  stupor 
and  coma.  In  others  there  is  intense  headache  with  violent  delirium, 
accompanied  by  extreme  restlessness  and  delusions.  Albuminuria  is  often 
present. 

Erysipelas  occasionally  affects  the  mucous  membrane  of  the  mouth, 
fauces,  and  larynx,  by  extension  from  without;  more  rarely  the  disease 
originates  in  the  mucous  membrane.  The  fauces  and  pharynx  in  such 
cases   are   red,  shiny,   and   cedematous,   and   there   is   marked   glandular 


220  GENERAL  DISEASES. 

swelling  at  the  angles  of  the  jaw.  Bullae  containing  turbid  serum  are 
often  seen.  They  soon  burst,  leaving  yellowish  white  membranous  patches. 
Extension  to  the  larynx  is  often  very  sudden,  and  gives  rise  to  intense 
dyspnoea,  which  may  be  rapidly  fatal,  unless  promptly  relieved  by  suitable 
measures. 

The  duration  of  cutaneous  erysipelas  is  variable.  In  uncomplicated 
cases  the  temperature  often  falls  by  crisis.  This  may  occur  as  early  as 
the  fourth  or  fifth  day,  or  be  delayed  for  ten  days  or  a  fortnight.  Simul- 
taneously the  inflammation  ceases,  and  there  is  a  general  amelioration  of 
symptoms.  Convalescence  is  sometimes  prolonged.  When  death  occurs 
in  simple  erysipelas,  it  is  usually  due  to  exhaustion  or  to  toxaemia. 

Complications. — Some  of  these  are  purely  local,  or  due  to  a  direct 
extension  from  the  original  seat.  One  of  the  most  important  is  local 
suppuration,  which  may  lead  to  a  general  septic  infection.  Meningitis 
apart  from  pyaemia  is  rare,  even  in  cases  where  brain  symptoms  have  been 
prominent.  Pneumonia  and  acute  nephritis  are  occasionally  met  with. 
Delirium  tremens  may  arise  in  drunkards.  A  condition  of  persistent 
oedema  or  elephantiasis  sometimes  follows  repeated  attacks  of  the  disease. 
Eczema,  lupus,  and  other  chronic  skin  diseases  are  often  much  reduced,  or 
even  cured,  by  an  attack  of  erysipelas,  and  a  shrinking  of  sarcomatous  and 
other  tumours  has  also  been  observed. 

Diagnosis. — In  the  fully  developed  disease  this  rarely  presents  any 
difficulty.  But  where  the  appearance  of  the  rash  is  delayed,  as  sometimes 
happens,  or  where  the  disease  originates  in  the  hairy  scalp,  an  early 
diagnosis  may  be  attended  by  the  greatest  difficulty.  In  differentiating 
erysipelas  from  other  cutaneous  affections,  reliance  is  to  be  placed  chiefly 
on  the  mode  of  onset,  the  definiteness  of  general  symptoms,  and  the 
characteristic  appearance  and  behaviour  of  the  rash. 

Prognosis. — Simple  cutaneous  erysipelas  is  not  a  fatal  disease,  and 
healthy  adults  very  rarely  die  of  it.  Advanced  age,  debility,  renal  disease, 
and  habits  of  intemperance  all  influence  the  prognosis  unfavourably.  As 
regards  the  attack  itself,  the  following  are  unfavourable  signs : — Persistent 
high  fever,  early  prostration,  extreme  restlessness,  excessive  diarrhoea, 
frequent  vomiting,  and  violent  delirium.  Erysipelas  spreading  from  the 
navel  in  the  new-born  is  an  extremely  fatal  disease. 

Treatment. — The  patient,  should  be  strictly  isolated,  especially  in 
hospital  practice,  and  suitable  precautions  taken  by  the  medical  practitioner 
and  those  in  attendance  on  the  patient  against  conveying  the  disease  to 
others.  As  the  disease  tends  to  run  a  short  and  favourable  course,  it  is 
certain  that  little  more  than  good  nursing  is  required  in  many  of  the 
cases.  The  general  treatment  should  aim  at  maintaining  the  strength  of 
the  patient,  and  with  this  object  a  light  and  nutritious  diet  and  a  judicious 
use  of  stimulants  are  indicated.  In  severe  cases,  and  in  the  old  and 
debilitated,  alcohol  must  be  freely  given.  Eestlessness,  delirium,  and 
insomnia  must  be  met  by  sedatives,  but  where  they  constitute  an  alarming 
symptom,  the  best  results  will  be  obtained  by  the  cautious  use  of  morphine 
or  hyoscine  hypodermically.  To  bring  down  the  temperature,  cold  or 
tepid  sponging  should  be  used  in  preference  to  antipyretic  drugs,  such  as 
antipyrine  and  antifebrin. 

It  is  very  doubtful  whether  any  drug  administered  internally  has  any 
influence  on  the  course  of  the  disease.  The  tincture  of  the  perchloride  of 
iron  in  doses  of  thirty  to  sixty  drops  every  three  or  four  hours  has  been 
highly  recommended  and  very  widely  employed.    The  subjects  of  erysipelas 


SEPTIC  DISEA  SES.  2  2 1 

are  remarkably  tolerant  of  the  drug.  Local  treatment  should  aim  at  ex- 
cluding air  from  the  inflamed  area,  relieving  pain  and  tension,  and  if 
possible,  at  checking  the  spread  of  the  inflammation.  Many  remedies, 
some  of  them  of  doubtful  value,  have  been  recommended  for  the  latter 
purpose.  Among  these  may  be  mentioned  painting  the  skin  with  collodion, 
iodine,  solutions  of  nitrate  of  silver,  of  perchloride  or  persulphate  of  iron, 
and  more  recently  with  ichthyol.  Some  of  these,  particularly  iodine  and 
ichthyol,  often  cause  much  pain.  The  injection  of  antiseptic  solutions 
beneath  the  skin  at  several  points  just  beyond  the  spreading  margin  is 
more  rational,  and  seems  deserving  of  further  trial.  Protection  from  the 
outer  air  is  best  obtained  by  painting  the  inflamed  skin  with  flexile 
collodion,  and  after  dusting  it  freely  with  fine  zinc  and  starch  powder, 
enveloping  it  in  cotton-wool.  Local  pain  is  most  effectually  relieved  by 
hot,  moist  applications.  In  many  cases  carbolic  fomentations  (1  in  40 
strength)  are  very  soothing.  Boric  fomentations  and  lead  fomentations 
(liq.  plumbi  5ij  ad  Oi.)  are  also  valuable.  Painting  the  skin  with  glycerin 
of  belladonna  in  combination  with  fomentations  has  also  given  good  results. 
All  hot  applications  should  be  renewed  frequently.  Cold  lead  lotion  and 
cold  water  applications  may  be  used  with  benefit  where  the  swelling  is 
slight.  Minute  linear  scarifications  have  been  recommended  where  the 
tension  is  extreme,  and  gangrene  is  feared.  Suppuration  must  be  dealt 
with  by  appropriate  surgical  means. 

W.  PASTEUR. 


SEPTIC  DISEASES. 

Syn.,  Fr.,  Maladies  septiques;  Ger.,  Wundinfections  Krankheiten. 

Speaking  generally,  these  affections  are  due  to  the  entrance  into  the  blood 
and  tissues  of  certain  living  micro-organisms  or  of  their  products.  In  the 
large  majority  of  cases  the  infection  of  the  system  starts  from  a  previously 
existing  wound  or  collection  of  pus  in  some  part  of  the  body.  Their  chief 
interest  to  the  physician  arises  from  the  fact  that  they  are  essentially 
general  diseases,  and  that  they  arise  occasionally  without  any  previous 
lesion,  so  far  at  least  as  can  be  ascertained  by  the  most  careful  examina- 
tion. The  bacteria  usually  concerned  in  these  affections  are  those  commonly 
associated  with  suppuration,  namely,  the  Staphylococcus  pyogenes  aureus 
or  alius  and  the  Streptococcus  pyogenes.  General  infections  have  also 
been  observed  in  association  with  the  Bacillus  coli  communis,  the  pneumo- 
coccus,  the  gonococcus,  and  others. 

Although  the  terms  saprsemia,  septicaemia,  and  pyaemia  are  of  some 
value  as  indicating  differences  in  the  kind  of  infection,  it  must  be  borne 
in  mind  that,  clinically,  no  hard-and-fast  line  can  be  drawn  between  them. 
Thus  a  streptococcic  infection  may  present  clinically  —  (a)  Sapraeniia, 
from  the  absorption  of  bacterial  products,  as  for  instance  the  case  of  a 
parametric  abscess  without  general  infection ;  (b)  septicaemia,  such  as  that 
which  constitutes  one  variety  of  puerperal  fever ;  and  (c)  pyaemia,  in  which 
metastatic  abscesses  develop  in  the  course  of  a  general  septicaemia. 

The  paths  of  secondary  infection  are  summarised  as  follows  by  Muir 
and  Ritchie  : — "  Eirst,  by  lymphatics.  In  this  way  the  lymphatic  glands 
may  be  infected,  and  also  serous  sacs  in  relation  to  the  organs  where  the 


222  GENERAL  DISEASES. 

primary  lesion  exists.  Second,  by  natural  channels,  such  as  the  ureters 
and  the  bile  ducts,  the  spread  being  generally  associated  with  an  inflam- 
matory condition  of  the  lining  epithelium.  In  this  way  the  kidneys  and 
liver  respectively  may  be  infected.  Third,  by  the  blood  vessels :  (a)  by  a 
few  organisms  gaining  entrance  to  the  blood  from  a  local  lesion  and  settling 
in  a  favourable  nidus  or  a  damaged  tissue,  the  original  path  of  infection 
being  often  obscure ;  (b)  by  a  septic  phlebitis  with  suppurative  softening 
of  the  thrombus  and  resulting  embolism ;  and  we  may  add,  (c)  by  a  direct 
extension  along  a  vein,  producing  a  spreading  thrombosis  and  suppuration 
within  the  vein.  In  this  way  suppuration  may  spread  along  the  portal 
vein  to  the  liver  from  a  lesion  in  the  alimentary  canal,  the  condition  being 
known  as  pyelo-phlebitis  suppurativa." 

Sapplemia. 

This  is  liable  to  occur  wherever  there  is  dead  or  injured  tissue 
undergoing  putrefactive  changes  in  contact  with  a  rapidly  absorbing 
surface.  It  probably  plays  an  important  part  in  the  so-called  traumatic 
fever,  and  constitutes  one  of  the  varieties  of  puerperal  fever.  The  severity 
of  the  symptoms  varies  with  the  dose  of  poison  absorbed.  The  onset  is 
sudden,  with  chill  or  rigor.  The  symptoms  are  in  the  main  those  of  fever : 
thirst,  headache,  anorexia,  rapid  pulse,  restlessness,  and  increasing  prostra- 
tion, leading  to  coma  and  death  unless  the  source  of  the  poison  is  removed 
by  appropriate  measures.  Severe  cases  of  pure  saprsemia  are  decidedly 
rare. 

Septicemia. 

In  this  form  of  septic  infection  the  invasion  of  the  body  may  proceed 
from  a  local  site,  as  in  puerperal  septicaemia,  or  post-mortem  or  other 
wounds,  or  the  disease  may  arise  without  discoverable  local  cause — 
idiopathic  or  cryptogenetic  septicaemia. 

Morbid  anatomy. — The  post-mortem  appearances  are  those  of  rapid 
decomposition  with  visceral  congestion.  The  blood  is  fluid  and  dark.  There 
is  marked  post-mortem  staining  of  the  interior  of  the  vessels.  The  heart 
is  flabby.  Ecchymoses  in  the  serous  membranes  are  common.  The  lungs 
are  congested.  The  spleen  is  large  and  soft,  and  the  liver  and  kidneys 
congested  and  swollen.  Neither  thrombi  nor  emboli  are  found.  The  signs 
of  peritonitis  are  often  present,  particularly  in  puerperal  cases.  The 
changes  at  the  site  of  inoculation  or  in  the  wound  vary  greatly. 

Symptoms. — In  a  typical  case,  after  wound  infection  the  disease 
commences  suddenly ;  within  a  few  hours,  or  at  most  two  or  three  days. 
The  temperature  either  rises  rapidly,  with  a  severe  rigor,  which  may  be 
repeated,  or  the  rise  is  more  gradual,  the  rigor  being  replaced  by  chilliness. 
It  usually  remains  high,  with  daily  remissions,  and  sometimes  with  inter- 
missions. The  course  of  the  temperature  in  a  well-marked  case  is  shown 
in  Fig.  36.  The  pulse  is  rapid  and  feeble,  and  the  heart  soon  loses  strength. 
The  tongue  is  red  at  the  edges  and  dry  on  the  dorsum.  There  is  complete 
anorexia,  and  gastro-intestinal  disturbances  are  common.  There  is  usually 
more  or  less  headache.  Delirium  may  set  in  early  and  pass  into  coma,  or 
the  mind  may  remain  clear  to  the  end.  Breathing  is  rapid,  and  there  may 
be  signs  of  general  bronchitis,  with  a  varying  degree  of  lividity.  The  urine 
frequently  contains  albumin.     Death  may  occur  as  early  as  the  second  or 


SEPTIC  DISEASES. 


223 


third  day.  If  life  is  prolonged  beyond  this,  the  patient  passes  into  the 
typhoid  state.  The  skin  becomes  sallow  or  jaundiced,  and  purpuric  spots 
often  appear.  Intractable  diarrhoea  is  apt  to  supervene,  and  death  from 
exhaustion  takes  place  usually  within  a  week.  The  milder  varieties  of  the 
disease  usually  occur  in  connection  with  suppuration  and  septic  wounds. 
Septicaemia  may  complicate  other  acute  diseases,  such  as  diphtheria  and 
typhoid  fever,  and  occasionally  supervenes  in  the  later  stages  of  Bright's 
disease  and  tuberculosis. 

Diagnosis. — The  diagnosis  presents  no  difficulty  where  there  is  an 
obvious  source  of  infection,  such  as  a  post-mortem  prick  or  dissection 
wound.  Where  the  source  of  infection  is  obscure  the  difficulty  is  often 
extreme.  The  discovery  of  streptococci  in  the  blood  may  assist  the  dia- 
gnosis, but  they  are  not  necessarily  present  in  the  specimen  obtained  for 
examination,  and  septicaemia  is  not  always  due  to  streptococcus  infection. 

From  saprsemia  the  disease  can  only  be  distinguished  by  the  greater 
prostration  which  accompanies  it.     The  symptoms  of  the  two  conditions 

June 


Fig.  36. — Temperature  chart  from  a  case  of  acute  septicaemia  ending  in  recovery. 

are  very  similar,  and  moreover  they  are  usually  associated.  The  distinction 
from  pyaemia  rests  chiefly  on  the  acuter  onset,  more  rapid  course,  more 
sustained  temperature,  and,  later  on,  the  absence  of  secondary  abscesses. 

Prognosis  and  treatment. — The  prognosis  in  severe  cases  is 
extremely  grave,  especially  in  cases  of  acute  puerperal  septicaemia,  which 
are  almost  invariably  fatal.  The  general  treatment  should  be  directed 
towards  maintaining  the  strength  of  the  patient  in  every  possible  way. 
Among  drugs,  quinine  is  probably  the  most  valuable.  The  hypodermic 
injection  of  anti-streptococcus  serum  has  been  largely  used  in  cases  of 
septicaemia  with  some  measure  of  success.  Its  use  should  be  limited  to 
cases  in  which  there  is  definite  evidence  of  a  streptococcic  infection. 


Pyemia. 

Pyaemia  may  be  described  as  that  form  of  septicaemia  in  which  the 
bacteria  which  invade  the  general  circulation  give  rise  to  the  formation 
of  multiple  abscesses  in  the  internal  organs,  and  in  various  other  parts  of 


224  GENERAL  DISEASES. 

the  body.  The  micro-organisms  most  commonly  concerned  are  streptococci 
and  staphylococci. 

Etiology  and  pathology. — In  the  large  majority  of  cases,  pyaemia 
arises  in  connection  with  a  pre-existing  wound  or  injury,  or  in  relation 
to  some  local  disease  process  which  lays  the  body  open  to  invasion  by 
one  or  other  of  the  pyogenic  bacteria.  In  this  way,  ulcers  of  the  intestine, 
or  of  other  mucous  membranes,  gonorrhoea,  prostatic  thrombosis,  otitis 
media,  empyema,  the  interior  of  the  uterus  after  parturition  or  abortion, 
etc.,  may  become  the  focus  of  infection.  In  very  exceptional  cases  no 
primary  focus  can  be  discovered  (idiopathic  pyaemia).  A  very  constant 
and,  probably,  an  essential  feature  of  pyaemia  is  the  occurrence  of  septic 
phlebitis  and  thrombosis  in  a  vein  adjacent  to  the  primary  focus.  The 
thrombus  becomes  impregnated  with  organisms,  softens,  disintegrates,  and 
small  fragments  containing  organisms  are  carried  as  emboli  into  the  general 
circulation.  These  become  arrested  in  the  organs  to  which  they  are  first 
carried,  and  there  give  rise  to  suppurative  infarctions  which  may  cause 
abscesses  of  considerable  size. 

The  situation  of  the  pyaemic  infarctions  and  secondary  abscesses  is 
governed  to  some  extent  by  the  course  of  the  blood  stream.  Wherever 
the  infective  emboli  are  discharged  into  the  general  venous  circulation, 
the  embolic  abscesses  occur  chiefly  in  the  lungs.  They  are  often  associated 
with  septic  pleurisy,  probably  by  direct  extension,  and  pericarditis  and 
peritonitis  may  also  occur.  Sometimes  infective  particles  pass  through 
the  lungs,  and  may  cause  foci  of  inflammation  in  the  heart  and  kidneys. 
When  the  source  of  infection  is  situated  within  the  area  drained  by  the 
portal  circulation,  the  chief  secondary  deposits  are  found  in  the  liver 
(portal  pyaemia).  In  cases  arising  as  acute  osteo-myelitis,  the  heart  and 
kidneys  may  be  the  organs  chiefly  affected.  Infection  of  the  endocardium 
is  very  liable  to  occur,  and  may  materially  modify  the  character  of  the 
clinical  features.  Vegetations  develop  on  the  affected  valve,  and  become 
covered  with  clot,  portions  of  which  may  be  carried  to  various  parts  of  the 
body,  where  they  give  rise  to  suppurative  infarctions,  notably  in  the  brain, 
spleen,  and  kidneys. 

The  general  appearances  of  the  body  after  death  are  the  same  as  in 
septicaemia.  The  nature  of  the  local  lesions  has  already  been  sufficiently 
indicated. 

Symptoms. — There  may  be  general  malaise  with  some  fever  for  a 
few  days  before  the  onset  of  acute  symptoms.  In  some  cases  phlebitis 
and  venous  thrombosis  can  be  made  out.  In  thrombosis  of  the  lateral 
sinus  there  may  be  severe  pain  and  tenderness  along  the  course  of  the 
vessel,  whilst  in  cases  of  wound  infection  local  changes  are  generally 
present.  Often  the  disease  begins  suddenly  with  a  severe  rigor,  followed 
by  profuse  sweating  and  great  exhaustion.  During  the  rigor  the  tempera- 
ture may  rise  to  104°,  or  higher,  and  falls  again  rapidly  during  the 
sweating  stage.  The  fever  continues  with  large  remissions,  interrupted  at 
irregular  intervals  by  fresh  rigors.  In  the  intervals  between  the  rigors 
the  pyrexia  may  be  only  slight,  and  it  is  not  unusual  for  the  temperature 
to  drop  below  normal  during  the  remission  following  a  rigor.  The  con- 
stitutional symptoms  are  well  marked.  The  expression  is  anxious,  and 
the  face  soon  grows  sallow  or  jaundiced.  Appetite  is  lost.  Vomiting  is 
common,  and  there  may  be  troublesome  diarrhoea.  The  tongue  is  dry. 
Prostration  is  marked,  the  breathing  is  hurried,  and  there  is  a  rapid  loss 
of  flesh.     Transient  erythema  in  various  Darts  of  the  body  is  common. 


SEPTIC  DISEASES. 


225 


The  pulse  is  frequent  and  weak.  The  first  cardiac  sound  is  usually  feeble, 
and  may  become  inaudible.  Various  cardiac  murmurs  may  be  heard  ;  these 
are  sometimes  functional,  but  may  also  indicate  the  presence  of  secondary 
endocarditis.  The  local  symptoms  vary  considerably,  and  may  be  but 
slightly  marked.  "When  the  lungs  are  affected  there  is  cough  and  dyspnoea, 
and  there  may  be  signs  of  patchy  consolidation  with  or  without  rales. 
Other  cases  present  the  signs  of  pleural  effusion  or  of  pericarditis.  The 
spleen  is  enlarged,  and  may  be  the  seat  of  acute  pain  as  the  result 
of  infarction.  There  may  be  signs  of  general  peritonitis,  especially  in 
puerperal  cases.  Abscesses  in  the  kidneys  usually  give  rise  to  pain  and 
albuminuria,  and  sometimes  to  htematuria.  Delirium  is  not  uncommon 
whilst  the  fever  is  high,  with  a  return  of  consciousness  in  the  intervals. 
In  some  cases  the  mind  remains  clear  for  a  considerable  time.  With  the 
onset  of  the  typhoid  state  muttering  delirium  is  common.  The  duration 
of  acute  cases  is  often  quite  short,  from  six  to  ten  days. 

In  the  more  chronic  forms  of  the  disease,  visceral  complications  are 
less  frequent,  and  suppuration  is  prone  to  occur  in  various  joints,  and  in 


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Fig.  37. — Temperature  chart  from  a  fatal  case  of  pysemia. 

the  muscles  and  subcutaneous  tissues.  The  temperature  is  irregular,  and 
chills  and  rigors  may  occur  at  long  intervals.  Some  patients  ultimately 
recover,  whilst  others  eventually  die  of  exhaustion. 

The  general  symptoms  of  portal  pyaemia  do  not  differ  from  those 
described  above.  The  type  of  the  disease  is  always  severe.  The  liver  is 
always  enlarged,  and  may  rapidly  attain  to  a  great  size.  The  spleen  is 
also  much  enlarged.  There  is  intense  pain  over  the  hepatic  region,  and 
marked  jaundice  and  ascites  are  present  in  some  cases. 

Diagnosis. — This  as  a  rule  only  presents  difficulties  in  cases  where 
the  primary  source  of  infection  is  obscure.  In  all  suspected  cases  a 
careful  search  must  be  made.  A  localised  osteomyelitis  may  easily  be 
overlooked,  as  may  also  a  gonorrhoea  or  a  prostatic  abscess.  Where  acute  ■ 
renal  symptoms  occur  early,  the  distinction  from  acute  Bright 's  disease  is 
not  easily  made.  Some  cases  present  a  somewhat  close  superficial 
resemblance  to  malaria,  but  the  diagnosis  should  seldom  present  any  real 
difficulty.  Malaria  rarely  resists  quinine.  The  resemblance  of  cases  of 
more  chronic  type  with  marked  diarrhoea  to  enteric  fever  is  sometimes 
very  close.  Osier  lays  stress  on  the  importance  of  marked  leucocytosis  in 
the  differential  diagnosis.  Haemorrhage  from  the  bowel  is  rarely  seen  in 
vol.  1. — I  c 


226  GENERAL  DISEASES. 

pyaemia.  Cases  of  pyaemia  have  a±so  been  mistaken  for  acute  tuberculosis. 
In  arthritic  cases  the  distinction  from  rheumatism  rests  chiefly  on  the 
persistence  of  the  joint  lesion,  the  absence  of  the  characteristic  sour  odour 
of  the  perspiration,  and  the  presence  of  other  signs  of  pyaemia. 

When  meningitis  or  uraemia  complicate  pyaemia,  the  general  symptoms 
may  be  to  a  great  extent  obscured  by  those  of  the  local  condition,  and  lead 
to  errors  in  diagnosis.  As  regards  ulcerative  endocarditis,  where  endo- 
cardial murmurs  are  present,  it  may  be  very  difficult  to  decide  whether 
the  vascular  lesion  is  part  of  a  general  infection,  or  whether  the  general 
symptoms  are  not  themselves  due  to  a  malignant  endocarditis. 

Prognosis  and  treatment. — The  prognosis  in  the  visceral  forms 
is  very  grave.  Cases  of  portal  pyaemia  hardly  ever  recover.  The  prognosis 
is  somewhat  more  hopeful  where  only  external  abscesses  occur.  The 
general  treatment  is  the  same  as  in  septicaemia.  Both  the  primary  lesion 
and  secondary  abscesses,  wherever  they  are  accessible,  should  be  dealt  with 
surgically,  and  if  the  infection  is  due  to  the  streptococcus,  the  serum 
should  be  employed. 

W.  PASTEUR. 


ACUTE  PNEUMONIA. 


Syn.,  Croupous  Pneumonia,  Lobar  Pneumonia,  Pleuro-pneumonia, 
Pneumonic  Fever.1 

An  acute  infective  fever,  apparently  dependent  on  the  invasion  of 
certain  micro-organisms,  especially  the  Diplococcus  pneumonias  (Frankel), 
or  pneumococcus  (of  which  there  would  seem  to  be  several  varieties), 
characterised  by  symptoms  and  signs  referable  to  local  inflammation 
of  lung,  and  by  grave  constitutional,  more  particularly  circulatory, 
disturbance. 

History. — From  early  times  pneumonia  was  spoken  of  as  a  separate 
disease,  but  the  dividing  line  between  true  acute  pneumonia  and  pleurisy 
was  not  so  defined  as  it  might  have  been.  The  predominance  of  lung 
symptoms  and  the  post-mortem  appearances  naturally  caused  pneumonia  to 
be  regarded  as  a  local  lung  process. 

During  the  past  half-century  the  infectiveness  of  pneumonia  has  come 
to  be  considered  both  at  the  bedside  and  in  the  laboratory.  At  the  present 
day  the  infective  nature  of  the  disease  is  recognised  by  the  large  majority 
of  competent  observers.  Discussion  continues  as  to  certain  etiological 
relationships,  but  the  main  thesis  as  to  its  infectiveness  is  admitted, — the 
specific  agent  in  its  production  being  the  Diplococcus  pneumonias  (Frankel), 
or  pneumococcus,  and  perhaps  the  Bacillus  pneumonias  (Friedlander).  More 
than  this,  there  is  a  growing  consensus  that  the  pulmonary  aspect  of  the 
disease  has  loomed  too  much  in  the  foreground.  The  disease  is  henceforth 
to  be  relegated  to  the  group  of  acute  infective  fevers.  The  local  (pulmonary) 
lesion  is  to  be  considered  analogous  to  the  throat  lesion  in  diphtheria  or 
scarlatina,  or  the  intestinal  lesion  in  typhoid.  The  local  lesion  is  accom- 
panied, to  a  greater  or  less  degree,  in  different  cases,  by  constitutional 
infection.  As  we  shall  see  later,  the  specific  organisms  have  been  dis- 
covered,  not    only   in    the    lung   but   also   in   the    pleura,   pericardium, 

1  The  name  Pneumonic  Fever  is  preferred  by  the  writer  as  the  best  descriptive  term,  both 
from  the  etiological  aud  clinical  standpoint.     It  is  justified  by  the  analogy  of  enteric  fever. 


ACUTE  PNEUMONIA  227 

endocardium,  peritoneum,  meninges,  kidneys,  spleen,  and  blood.  Indeed, 
it  has  been  demonstrated  that  the  organisms  may  be  recognised  in  these 
organs  at  a  date  prior  to  their  appearance  in  the  lung. 

Etiology. — From  what  has  just  been  said,  it  is  apparent  that  the 
present-day  conception  of  pneumonia  has  displaced  some  of  the  etiological 
views,  or  at  least  relegated  them  to  a  position  of  less  importance.  It  will 
be  convenient  to  consider  the  subject  under  two  heads — (1)  Specific 
(exciting)  factors ;  (2)  auxiliary  (predisposing)  factors. 

1.  Specific  factors. — The  claim  of  specific  influence  has  been  advanced 
on  behalf  of  more  than  one  organism.  There  is  pretty  general  agreement 
that  the  most  constant  and  certain  is  the  Diplococcus  pneumoniae  (Frankel). 
The  Bacillus  (Micrococcus)  pneumonia?  (Friedlander)  is  present  in  a  con- 
siderable number  of  cases.  These  organisms  may  sometimes  be  discovered 
together,  or  the  one  may  alone  be  present  without  any  determinable 
difference  in  the  clinical  history.  The  two  organisms  resemble  each  other 
not  a  little,  but  are  separable  by  staining  and  culture  methods,  and  by 
inoculation  experiment. 

The  Diplococcus  pneumonia?  (Frankel)  is  elliptical  in  form,  or  lance- 
shaped  (31.  lanceolatus).  As  found  in  the  sputum,  it  is  generally  paired  and 
encapsuled  ("  capsule-coccus  ").  A  cover-glass  preparation,  treated  in  the 
usual  way  by  glacial  acetic  acid,  is  readily  stained  by  means  of  gentian- 
violet  dissolved  in  aniline  water  (i.e.  distilled  water  saturated  with  aniline 
oil.  The  diplococcus  may  be  discovered  sometimes  in  the  saliva  of 
apparently  healthy  persons,  and  for  long  in  that  of  patients  who  have 
suffered  from  pneumonia.  It  has  therefore  been  maintained  that  its  causal 
influence  is  small.  But  its  constancy  in  the  expectoration  of  the  pneumonic 
subject  is  opposed  to  this ;  and  the  local  and  constitutional  effects  produced 
by  inoculation  with  a  pure  culture  substantiate  strongly  the  specific 
position.  More  recent  observations  (Eyre,  Washborn.)  indicate  that  there 
are  several  different  varieties  of  pneumococcus.  The  different  varieties  have 
been  obtained  from  varying  sources,  e.g.  the  sputum  of  the  pneumonic 
patient,  the  pus  from  the  meninges  in  pneumonia,  the  lung  tissue  itself, 
pus  from  an  empyema  following  pneumonia,  and  the  saliva  of  the  patient. 
These  varieties  have  been  shown  to  be  possessed,  not  onlv  of  different 
biological  characters,  but  of  different  degrees  of  virulence. 

If  their  causal  influence  be  admitted,  how  do  the  organisms  obtain  an 
entrance  ?  This  is  effected  by  way  of  the  respiratory  passages.  There  is 
no  reason  to  doubt  the  observation  that  the  organisms  are  present  on 
apparently  healthy  surfaces.  In  this  view  the  organisms  are  frequently 
ranged  in  menacing  line.  It  may  be  that  the  disease  is  caused  by  the 
presence  of  an  unusually  large  army  of  these,  or,  as  is  more  likely,  by  their 
successful  invasion  of  tissues  which  have  been  weakened  by  one  or  other 
of  the  auxiliary  causes,  to  be  detailed  presently.  It  is  a  fact  of  much 
interest  that  the  organisms  have  been  determined  on  the  floor  and  roof  in 
certain  dwellings  where  pneumonia  has  been  recurrent  from  time  to  time. 

By  way  of  the  respiratory  passages  the  lungs  are  reached,  and  here  the 
more  evident  lesion  is  induced.  But  that  this  is  not  all  is  proved  by  the 
discovery  of  the  organisms  in  pleura,  pericardium,  endocardium,  peritoneum, 
meninges,  kidney,  spleen,  and  blood,  and  by  the  grave  constitutional 
implication.  The  presumption  is  that  the  constitutional  disturbance  is  the 
effect  of  a  toxine  produced  by  the  organism.  This  so-called  pneumotoxine 
has  been  separated  in  glycerine  extract  from  cultures  of  the  pneumococcus. 
"When  injected  into  animals,  the  toxine  induces  pyrexia  and  other  grave 


228  GENERAL  DISEASES. 

symptoms,  and  finally  would  appear  to  produce  within  the  circulation  another 
body  possessed  of  antagonising  properties,  to  which  the  name  antipneumo- 
toxine  has  been  given.  This  antipneumotoxine,  it  is  maintained,  can  be 
separated  from  the  serum  of  pneumonic  patients  subsequently  to  the  crisis. 
It  would  seem  likely  that  the  bone  marrow  is  one  of  the  seats  of  produc- 
tion of  the  immunising  substance.  Eeference  is  made  further  to  this  aspect 
of  the  disease  under  the  head  of  "  Treatment." 

It  has  been  long  recognised  that  pneumonia  is  endemic,  or,  at  least,  its- 
occurrence  is  more  frequent  in  certain  localities.  When  a  footing  has  been 
attained,  it  would  appear  never  to  leave  a  district  entirely.  This  may 
depend  on,  among  other  causes,  the  fixity  with  which  the  organism  clings  to 
places  once  affected.  As  already  stated,  the  pneumococcus  has  been 
discovered  on  the  floor  and  roof  of  dwellings  (prisons),  and  may  be  found, 
for  more  than  a  year,  in  the  saliva  of  patients  who  have  recovered.  Natives 
of  a  district  where  it  is  common  seem  to  suffer  more  than  visitors.  Its 
occurrence  in  epidemic  form  is  well  established.  Many  physicians  have 
reported  illustrations  of  this,  as  for  instance  the  appearance  of  three  or 
more  cases  in  one  household.  Generally  such  instances  have  occurred  in 
relation  to  overcrowding,  as  for  example  in  prisons,  workhouses,  barracks, 
and  schools.  An  epidemic  of  the  kind  occurred  on  board  H.M.  training- 
ship  Caledonia  some  seven  years  ago,  when  a  large  number  of  cases  were 
admitted  to  the  Edinburgh  Boyal  Infirmary.  Sometimes  the  outbreak  has 
been  associated  with  other  epidemics,  e.g.,  the  fatal  pneumonia  which  was 
grafted  on  influenza  during  the  recent  epidemic  of  that  disease,  and  similarly 
during  the  great  epidemic  in  1847.  The  question  of  degree  of  contagiousness 
is  still  a  moot  one.  But  there  is  reason  to  maintain  that,  within  limits,  the 
fact  of  contagiousness  has  been  established.  1  have  seen  more  than  one 
instance  in  hospital  where  old  inmates  of  the  ward,  suffering  from  other 
disease,  have  become  infected  by  a  pneumonic  new-comer.  Instances  of  the 
carriage  of  the  disease  to  a  third  person  have  also  been  reported. 

2.  Auxiliary  factors.— These  are  either  (a)  general,  or  (5)  individual. 

(a)  General.— Climate  seems  to  play  per  se  an  unimportant  part. 
Pneumonia  occurs  frequently  enough  in  all  different  climates.  Its  occur- 
rence would  seem  to  be  influenced  by  variability  rather  than  actual  coldness  of 
climate.  Hence  it  is  commoner  in  temperate  than  in  very  warm  or  cold 
regions.  The  seasonal  variation  in  frequency  is  considerable,  and  differs  in 
different  parts  of  the  world.  In  the  United  Kingdom,  pneumonia  is 
commoner  during  winter  and  spring  than  during  summer  and  autumn,  and, 
as  a  rule,  during  spring  than  during  whiter.  This  is  probably  a  further 
expression  of  its  dependence  on  sudden  alterations  of  temperature,  and  the 
occurrence  of  chill. 

Similarly,  constant  exposure  to  cold  is  less  likely  to  predispose  than 
sudden  cooling  after  being  heated,  with  perhaps  accompanying  fatigue. 
Country-people  and  sailors  are  less  frequently  affected  than  dwellers  in  busy 
centres,  where  overcrowding,  insufficient  ventilation,  alcoholism,  and 
privation  are  auxiliary  agents  of  the  first  moment. 

(b)  Individual. — Sex  is  of  interest,  in  so  far  as  pneumonia  is  distinctly 
commoner  in  men  than  in  women,  while  the  fatality  of  the  disease  is  greater 
in  women.  Eegarding  age,  statistics  vary  somewhat.  But  summing  those 
up,  we  may  aver  that  it  is  especially  common  to  10  years  of  age,  that  it  is 
less  common  thereafter  till  about  25,  that  it  is  common  between  this- 
and  45,  and,  thereafter,  is  common  enough  till  the  close  of  life. 

The  previous  health  of  the  patient  is  an  element  of  importance.    It  has 


ACUTE  PNEUMONIA.  229 

been  calculated  that  not  more  than  one-third  of  pneumonic  patients  can 
show  a  good  record.  The  predisposing  tendency  of  disease  may  be  seen  both 
as  regards  acute  and  chronic  processes.  Of  acute,  the  most  familiar  examples 
are  the  fevers,  in  the  wake  of  several  of  which  pneumonia  is  apt  to  develop. 
Notably  is  this  the  case  with  influenza,  typhus,  and  typhoid.  Similarly,  an 
injury  to  the  lung,  it  may  be  a  contusion  or  something  more  severe,  is  apt  to 
be  followed  by  pneumonia  (contusion  pneumonia).  Or  pneumonia  may 
be  dependent  on  the  passage  of  foreign  bodies  into  the  lungs.  Chronic 
disease,  either  of  the  respiratory  apparatus  or  general,  is  a  frequent  pre- 
cedent. Thus  pneumonia  may  supervene  on  bronchitis  or  tuberculous  dis- 
turbance of  the  lung,  or  albuminuria,  or  diabetes,  or  alcoholism,  or  nervous 
disease.  The  relationship  of  pneumonia  to  some  of  these  is  significant, 
and  is  further  discussed  under  "  Prognosis."  Lastly,  it  is  to  be  noted  that  a 
previous  attack  of  pneumonia  does  not  confer  immunity.  On  the  contrary, 
it  seems  to  increase  the  liability.  Cases  are  on  record  where  many  attacks 
(in  one  instance,  as  many  as  twenty-eight)  have  been  passed  through. 

Morbid  anatomy. —  The  morbid  changes  are  centred  especially  in 
the  lungs,  but  are  to  be  sought  for  also  in  relation  to  a  number  of  other 
organs. 

The  pulmonary  process  is  essentially  a  fibrinous  inflammation.  It 
involves  continuously  one  lobe  or  a  portion  of  it,  or  may  involve  an  entire 
lung  or  portions  of  both.  An  entire  lung  and  as  much  as  two-thirds  of  the 
pulmonary  tissue  of  the  other  side  may  be  implicated.  Double  pneumonia 
is,  however,  much  less  common  than  one-sided.  Occasionally  isolated 
patches  may  suffer,  scattered  irregularly  throughout  one  or  both  lungs. 
On  the  whole,  the  right  lung  appears  to  be  more  frequently  affected  than 
the  left.  Certainly  the  lower  lobes  are  affected  more  commonly  than  the 
upper.  The  inflammation  results  in  the  exudation  of  a  solid  material  in 
the  alveoli — the  clinically-determinable  consolidation. 

Four  stages  in  the  inflammatory  process  may  conveniently  be  recognised 
— (1)  Engorgement  or  congestion ;  (2)  red  hepatisation ;  (3)  grey  hepat- 
isation ;  (4)  resolution  or  liquefaction. 

Engorgement  or  congestion. — The  lung  is  deep  red  in  colour,  changing 
to  brighter  red  on  exposure,  and  is  unusually  firm  and  heavy.  It  is 
moulded  by  the  pressure  of  the  finger,  which  squeezes  out  blood-stained 
fluid  and  less  air  than  normally.  As  the  process  advances  the  air  is  more 
and  more  replaced  by  exudation.  Microscopic  examination  shows  a  greater 
or  less  degree  of  desquamation  of  the  epithelial  cells  lining  the  alveoli 
and  engorgement  of  the  capillaries.  The  duration  of  this  stage  may  be 
reckoned  at  from  twenty-four  to  thirty-six  hours. 

Red  hepatisation. — The  lung  is  of  brownish  red  colour,  bulky,  firm, 
and  heavy.  The  pleural  surface  is  turbid,  generally  carries  some  fibrinous 
exudation,  and  may  show  small  hsemorrhagic  extravasations.  The  surface 
may  be  slightly  marked  by  the  ribs.  There  may  be  some  fluid  effusion  in 
the  pleural  sac.  In  rare  instances  the  pleural  effusion  is  more  abundant, 
and  may  be  serous,  seropurulent,  or  even  purulent.  On  section,  the  luno- 
is  found  to  be  solid — hepatised — in  part  or  whole,  as  indicated  above.  In 
colour  it  is  bright  red,  tending  later  to  assume  the  appearance  of  red 
granite.  Here  and  there  haemorrhagic  areas  may  be  discovered.  Sur- 
rounding the  hepatised  areas  there  is  often  some  evidence  of  osdema  of 
lung  tissue.  From  the  cut  surface  there  exudes  a  brownish  red,  muddy 
liquid.  The  bronchial  glands  are  usually  enlarged.  Microscopic  exami- 
nation shows  that  the  alveolar  spaces  are  distended  with  a  firm  fibrinous 


23o  GENERAL  DISEASES. 

material,  in  which  may  be  seen  detached  epithelial  cells  and  red  blood 
corpuscles  in  varying  quantity,  and  one  or  all  of  the  micro-organisms  which 
have  been  described.  The  character  of  the  exudation  explains  the  clinical 
appearances  of  the  sputum.  The  duration  of  this  stage  may  be  reckoned 
as  some  two  to  four  days,  the  process  passing  gradually  on  towards  the 
next  stage. 

Grey  hepatisation. — The  lung  is  now  of  paler  hue,  varying  from  greyish 
red  to  yellowish  grey.  The  pleural  surface  generally  shows  more  distinct 
fibrinous  exudation.  The  organ  is  evidently  heavy,  weighing  perhaps  some 
two  or  three  pounds  more  than  normal.  On  section,  the  lung  is  solid  as 
before.  In  colour  it  shows  varying  shades  of  grey,  according  as  the  exuda- 
tion has  become  more  or  less  decolorised,  and  is  happily  compared  to  grey 
granite.  The  surface  has  a  granular  aspect.  The  lung  tissue  tends  to  be 
more  friable,  and  a  cut  portion  sinks  in  water.  The  liquid  which  escapes 
is  dirty  grey  in  colour,  and  still  more  turbid.  From  the  cut  bronchioles, 
small  casts  may  occasionally  project.  Microscopic  examination  shows  that 
the  exudation  is  less  fibrinous,  and  therefore  less  tenacious.  Leucocytes 
are  present  in  abundance,  in  different  degrees  of  fatty  degeneration.  The 
final  resultant  is  the  gradual  replacement  of  the  fibrinous  exudate  by  a 
more  fluid,  flaky  material. 

Resolution  or  liquefaction. — The  lung  remains  of  greyish  hue,  and  is 
conspicuously  soft  and  friable.  On  section,  the  firm  aspect  has  disappeared. 
The  alveolar  plugs  drop  out  easily,  and  there  wells  in  large  abundance  from 
the  cut  surface  a  more  uniform,  greyish  yellow  fluid — the  debris  resulting 
from  the  process  of  fatty  degeneration.  This  material  is  readily  absorbed, 
and  little  of  it  sees  the  light  of  day.  Indeed,  the  whole  course  may  be 
passed  through  without  much  expectoration.  The  exhibition  of  expector- 
ants to  aid  in  its  removal  has  no  pathological  warrant,  and  is  bad  practice. 
The  visible  expectoration  is  largely  bronchial  in  origin.  In  the  course  of 
a  week  from  the  commencement  of  resolution — in  uncomplicated  cases — 
the  lung  may  have  recovered  its  normal  appearance  without  any  trace  of 
the  grave  disturbance  through  which  it  has  passed. 

Thus  far  we  have  considered  the  appearances  in  the  course  of  a  fairly 
simple  pneumonia.  Even  here  it  must  be  admitted  that  the  limits  of  the 
stages  cannot  be  exactly  fixed  in  every  case.  Further,  in  a  given  lung,  at 
any  one  time,  there  may  be  evidence  of  two  or  even  three  stages  simul- 
taneously. Lastly,  it  is  to  be  remembered  that  cases  may  abort,  and 
correspondingly  the  anatomical  changes  stop  short,  say  at  the  stage  of 
engorgement. 

From  the  pleural  surface,  the  inflammation  may  pass  to  the  pericardium, 
and,  more  rarely,  to  the  peritoneum.  The  pericarditis  shows  the  usual 
appearances  of  that  condition,  but  the  pneumococcus  may  be  discovered  in 
the  fibrinous  exudation.  Endocarditis  may  also  be  present,  either  simple 
or  ulcerative,  and  the  specific  micro-organism  be  discoverable.  The  right 
heart  is  generally  distended  with  a  firm  clot,  which  may  be  traced  far  into 
the  pulmonary  artery.  The  branches  of  the  pulmonary  artery  usually 
remain  pervious  throughout  the  whole  course  of  the  disease,  and  the  cir- 
culation, if  slowed,  is  maintained  sufficiently.  In  the  kidneys  there  may- 
be evidence  of  nephritis.  The  pneumococcus  has  been  discovered  in  the 
capillaries  and  veins.  The  spleen  may  be  enlarged,  and  sometimes  a 
croupous  condition  of  the  gastro-intestinal  tract  is  found.  Other  foci  of 
infective  inflammation  may  be  present  as  in  the  meninges.  The  anatomical 
appearances  of  these  conditions  are  described  elsewhere.     All  this  points 


ACUTE  PNEUMONIA. 


231 


to  a  systemic  infection.     It  has,  indeed,  been  suggested  that  the  lung  mani- 
festations are  not  primary  but  secondary  to  the  systemic  infection. 

Where  the  natural  termination  in  liquefaction  and  absorption  does  not 
take  place,  there  may  be  evidence  of  various  morbid  conditions.  More 
especially,  gangrene  may  occur,  with  characteristic  odour  and  destruction 
of  tissue,  which  are  described  elsewhere.  Termination  in  suppuration, 
whether  diffuse  or  localised  (abscess),  is  not  common.  The  pus  may  burrow 
in  various  directions,  more  particularly  into  the  bronchi,  through  which  it 
is  evacuated.  Or  the  pus  may  burst  into  the  pleural  sac,  giving  rise  to  one 
variety  of  empyema.  Lastly,  the  process  may  sometimes  remain  chronic, 
the  lung  assuming  a  cirrhotic  appearance.  The  relations  of  cirrhosis  to 
the  disease  under  consideration  are  not  quite  certain.  It  is  difficult  to  say 
to  what  extent  the  lung  was  damaged  before  the  attack  of  pneumonia.  As 
has  been  suggested  clinically,  the  pneumonic  process  may  have  been  deter- 
mined in  a  lung  already  disturbed.  Doubtless  this  statement  applies  to 
those  cases  which  have  been  supposed  to  become  tuberculous  in  the  wake  of 
pneumonia.  In  some  of  these,  at  least,  pneumonia  was  determined  in  a 
tuberculous  lung,  and  the  pneumonic  condition  first  of  all  drew  attention  to 
the  chronic  consolidation.  I  have  observed,  in  a  number  of  patients  who 
have  died  of  pneumonia,  tuberculous  areas  of  varying  sizes  of  comparatively 
old  date.  Had  these  patients  lived,  and  the  tuberculous  condition  been  dis- 
covered later  clinically,  the  condition  might  probably  have  been  misinter- 
preted as  a  consequence  of  pneumonia.  Caseation  does  not  occur  in  such 
cases  apart  from  tuberculous  infection. 

Symptomatology. — The  clinical  picture  of  acute  pneumonia,  or 
pneumonic  fever,  varies  much.  It  varies  at  different  seasons  and  in 
different  localities.  It  varies  with  the  age  of  the  patient,  and,  especially, 
it  varies  according  to  the  condition  of  the  patient,  precedent  to  the  attack. 
There  has  been  a  tendency  sometimes  to  speak  of  pneumonia  as  almost 
constant  in  its  course  and  physical  signs.  Nothing  could  be  a  greater 
mistake.  The  more  one  studies  cases  of  pneumonia,  the  more  one 
recognises  the  wideness  of  variability.  It  will  be  convenient,  first,  to 
describe  shortly  the  leading  features  of  the  disease  as  it  occurs  suddenly, 
in  an  apparently  healthy  adult  under  middle  life,  and  then  to  indicate  the 
more  frequent  deviations  from  this  in  different  cases. 

The  incubation  period  has  not  been  determined  with  certainty.  Till 
recently,  observation  was  not  directed  to  the  point.  It  is  probably  short, 
and  has  been  approximately  fixed  at  from  one  and  a  half  to  two  days. 

The  invasion  is  sudden  and  heralded  by  a  rigor  of  varying  intensity, 
so  that  the  patient  can  fix  pretty  well  the  beginning  of  the  illness.  The 
patient  usually  experiences  severe  pain  in  the  side,  often  described  as 
stabbing.  This  is  referred  commonly  to  the  mammary  or  axillary  areas, 
or  to  a  corresponding  point  behind,  or  it  may  be  lower  down.  It  is 
increased  by  the  respiratory  movement,  which  becomes  accordingly  more 
shallow  and  frequent.  The  shallowness  is  protective,  and  the  increased 
frequency  is  partly  complementary  to  the  shallowness,  and  partly  the  ' 
expression  of  the  fever.  The  patient  is  manifestly  dyspnoeic,  and  speech 
tends  from  this  cause  to  be  gasping.  Following  the  rigor,  which  may  last 
ten  to  twenty  minutes  or  more,  a  high  pyrexia  is  registered. 

The  appearance  of  the  patient  at  this  stage,  say  on  the  second  day,  is 
characteristic.  He  generally  lies  on  his  back.  The  prostration  is  consider- 
able. The  face  is  flushed,  it  may  be  faintly  cyanosed  or  dusky.  The  aire  nasi 
move  actively  and  rapidly.     The  rate  of  respiration  is  evidently  increased. 


232  GENERAL  DISEASES. 

The  expression  is  painful  and  anxious.  Eound  about  the  mouth  there  is 
frequently  an  eruption  of  herpes  labialis.  The  skin  is  felt  to  be  intensely  hot, 
the  temperature  reaching  probably  103°  to  104°  F.  The  pulse  is  rapid,  full, 
and  bounding,  though  not  quickened  proportionately  to  the  respiration 
rate  so  much  as  in  other  fevers.  A  short,  painful  cough  shakes  the 
patient,  and  is  not  easily  restrained.  Expectoration  is  scanty,  consisting  of 
a  more  or  less  blood-stained,  air-containing  mucus,  of  extreme  viscosity, 
which  renders  discharge  difficult. 

The  disease  runs  its  course  approximately  in  a  week.  During  this 
time  the  temperature  continues  elevated,  with  morning  remissions  of 
perhaps  a  degree  or  so.  Finally,  it  falls  suddenly  to  the  normal  or  below 
the  normal  in  the  course  of  a  few  hours,  the  crisis  occurring,  it  used  to  be 
supposed,  preferably  on  an  odd  day,  the  fifth,  seventh,  or  ninth.  While 
the  pyrexia  lasts,  the  patient's  distress  continues.  More  particularly  there 
is  gradual  prejudice  of  the  circulation,  the  pulse  becoming  soft,  often 
dicrotic  and  irregular.  Some  degree  of  delirium  frequently  supervenes. 
The  tongue  is  loaded  with  a  white  fur.  Appetite  and  digestion  are 
variously  disturbed,  the  former  being  sometimes  wonderfully  maintained. 
The  urine  is  high-coloured,  sometimes  contains  albumin,  and  shows  a 
marked  diminution  of  chlorides.  The  physical  signs,  which  develop  hi 
the  lung  with  advancing  consolidation,  are  also  variable,  and  will  be 
discussed  more  fully  presently.  With  the  critical  fall  of  temperature  the 
patient's  distress  quickly  disappears,  and  the  pulse  improves  correspond- 
ingly. Within  a  few  hours  he  exchanges  a  state  of  grave  malaise  for  one 
of  comparative  well-being.  Convalescence  is  comparatively  rapid  and  easy, 
the  respiratory  and  circulatory  disturbances  disappearing  from  day  to  day. 

The  variability  of  the  course  makes  it  desirable  that  we  discuss  some 
of  the  symptoms  in  greater  detail. 

The  invasion  is  not  always  so  sudden  as  has  been  described.  Pneumonia 
may  supervene  as  a  complication  of  some  precedent  condition,  e.g.  influenza 
or  other  fever,  or  it  may  develop  in  the  wake  of  bronchitis,  from  which  at 
first  it  may  be  discriminated  with  difficulty.  Apart  from  this,  premonitory 
symptoms  of  malaise,  loss  of  appetite,  sleeplessness,  and  the  like,  may  occur 
during  several  days.  Sometimes,  in  place  of  a  pronounced  rigor,  there 
occurs  repeated  shivering  or  sense  of  chilliness.  Occasionally  the  rigor  is 
replaced  by  vomiting,  sudden  loss  of  consciousness,  or  convulsions. 

General  symptoms. — The  temperature  curve  is  not  so  constant  as  the 
foregoing  description  might  suggest.  In  certain  instances,  notably  in  children 
sometimes,  or  where  fever  has  existed  before  the  development  of  the  pneu- 
monia, the  ascent  is  less  sudden.  A  day  or  two  may  elapse  before  the 
maximum  is  reached.  Again,  the  temperature  may  run  up  to  106°  to  107°. 
On  the  whole,  however,  hyperpyrexia  is  not  common.  The  curve  tends  to 
be  higher  in  children  and  alcoholic  subjects.  Although,  as  a  rule,  fairly 
constant,  the  pyrexia  is  subject  to  greater  remissions  apart  from  evident 
cause,  resembling  those  in  tuberculous  pleurisy.  Occasionally  the  pyrexia 
aborts  as  soon  as  the  third  day.  Or  there  may  be  a  sudden  drop,  what  has 
been  termed  a  pseudo-crisis,  to  be  followed  by  a  return  of  pyrexia.  The 
true  crisis  may  occur  at  any  date,  from  the  fifth  day  onwards,  and  no  stress 
is  to  be  laid  on  the  supposed  predilection  for  the  odd  days.  It  may  be 
delayed  till  the  end  of  the  second  week.  While  a  crisis  is  to  be  looked  for, 
the  temperature  may  fall  more  slowly  by  lysis,  the  temperature  swinging 
for  days  before  finally  settling  to  normal.  The  normal  course  of  con- 
valescence may  be  interrupted  by  the  reappearance  of  pyrexia.     This  is 


ACUTE  PNEUMONIA.  233 

seldom  a  matter  of  importance.  A  true  recrudescence  is  extremely  rare. 
In  very  feeble  subjects,  pneumonia  may  be  passed  through  without  much 
pyrexia. 

The  respiratory  phenomena  may  be  more  in  the  background.  As  we 
shall  see  presently,  there  are  cases  of  pneumonia  without  evident  lung 
symptoms.  Pain  in  the  side  may  not  be  complained  of.  As  a  rule,  how- 
ever, some  degree  of  this  is  present,  on  inspiration.  It  is  generally 
one  of  the  first  symptoms  to  disappear.  The  pain  is  most  frequently 
referred  to  the  areas  which  have  been  mentioned,  but  sometimes  to 
the  abdomen,  or  indeed  to  the  other,  that  is  the  apparently  healthy 
lung.  The  pain  is  doubtless  pleural  in  seat,  and  to  be  attributed  to  an 
hypersesthetic  condition  of  the  nerves  in  the  inflamed  area.  As  a  rule,  the 
rate  of  respiration  is  much  increased,  ranging  from  30  to  60,  or  even 
more  per  minute.  The  relation  of  respiration  to  pulse  is  consequently  dis- 
turbed. In  place  of  the  normal,  1  to  4-5,  it  may  be  as  1  to  2,  or  1  to  1*5, 
The  breathing  is  superficial  and  the  expiration  often  grunting.  Cough 
varies  in  intensity  in  different  cases.  It  is  a  less  conspicuous  symptom  in 
elderly  patients.  It  is  usually  painful,  and  may  induce  serious  circulatory 
perturbation,  as  may  be  observed  on  feeling  the  soft  dicrotic  pulse  during 
the  effort.  The  cough  must  therefore  be  regarded  as  a  symptom  of  some 
moment.  A  troublesome  spasm  of  coughing  is  sometimes  thoughtlessly 
induced  during  the  auscultation  of  a  patient,  by  asking  him  to  breathe 
deeply.  It  may  likewise  be  induced  during  the  effort  of  swallowing.  The 
cough  would  seem  to  be  abundant,  in  proportion  as  the  pleural  surface  of 
the  lung  is  implicated. 

The  expectoration  is  often  most  characteristic,  but  it  may  be  absent,  as 
in  children.  In  typical  form  it  is  scanty,  extremely  viscid,  so  that  the 
sputum  jar  may  be  turned  over  without  loss,  full  of  air  bells,  and  of  a 
colour  ranging  from  saffron-green  to  dull  red,  or  rust-like.  The  colour 
depends  on  the  intimate  admixture  of  blood  in  different  proportion.  Less 
altered  red  blood  corpuscles  may  be  determined  microscopically,  as  also 
epithelial  and  mucous  cells  and  fibrinous  casts,  usually  minute,  but  some- 
times of  considerable  size,  showing  evidence  of  dichotomous  branching. 
The  Diplococcus  pneumonias  may  be  demonstrated  by  the  staining  methods 
already  described.  Such  characteristic  expectoration  may  for  a  clay  or 
two  be  preceded  by,  or  be  intermingled  with,  sputum  of  muco-purulent 
character.  Sometimes  it  is  more  evidently  sanguineous,  it  may  be  even 
pure  blood.  At  other  times  it  is  much  more  watery  in  character,  as  the 
result  of  accompanying  oedema.  The  watery  expectoration  may  assume  a 
dirty,  deep  brown  colour — the  well-recognised  "  prune  juice  "  expectoration, 
of  evil  omen.  Chemical  examination  shows  that  the  pneumonic  sputum 
contains  an  excess  of  chlorides,  and  is  wanting  in  alkaline  phosphates, 
which  are  abundantly  present  in  catarrhal  discharge.  Further,  while  in 
the  latter  there  is  more  sodium  than  potassium  present,  in  pneumonic 
expectoration  sodium  is  present  in  considerable  excess. 

The  circulatory  phenomena  are  of  the  first  importance.  The  outlook 
from  day  to  day  is  affected  more  by  the  degree  of  prejudice  of  the 
circulation  than  by  any  other  factor.  The  pulse  rather  than  the  lungs  is 
the  physician's  weather-glass.  Even  in  strong  subjects  the  pulse  rate  is 
increased  to  100  or  more.  In  children  this  is  exceeded  greatly.  In  old 
enfeebled  subjects  it  may  not  be  so  high.  As  a  general  rule  in  adults  a 
marked  increase  of  rate  is  to  be  viewed  with  suspicion,  and  carefully 
watched.     Full  and  bounding  at  first,  it  tends  to  become  softer  from  day 


234  GENERAL  DISEASES. 

to  day,  and  may  be  dicrotic.  At  this  stage  it  is  remarkable  what  a 
disturbing  influence  is  exerted  in  weakly  subjects  by  the  effort  of  coughing 
— an  instructive  observation  in  respect  of  the  necessity  of  the  patient's 
avoiding  all  exertion.  The  gentlest  movement  of  the  patient  from  one 
side  to  the  other  may  produce  the  same  effect.  Perturbation  may  be 
discoverable  with  the  alternating  movements  of  respiration.  Increase  of 
pulse  rate,  combined  with  advancing  softness  and  irregularity  in  force  and 
time — the  beat,  perhaps,  not  certainly  countable  at  the  wrist — is  of  grave 
omen.  It  may  be  the  precursor  of  the  crisis,  but  if  this  do  not  quickly 
supervene  the  hope  of  recovery  is  slender.  Death  may  occur  from 
circulatory  failure  at  almost  any  point.  It  may  be  the  final  stage  in  the 
progressive  stasis,  which  has  just  been  sketched.  The  extremities  become 
blue  and  cold,  consciousness  is  abolished,  and  the  patient  dies  from  loss  of 
hgematosis.  Or  the  heart  may  be  suddenly  overcome,  and  the  patient  die 
instantaneously,  when  there  seemed  little  cause  for  alarm.  This  may  be 
associated  with  exertion,  or  with  the  rapid  extension  of  the  pneumonic 
process.     It  is  ultimately  traceable  to  the  action  of  the  toxine. 

The  "blood  shows  certain  altered  characters.  The  proportion  of  fibrin  is 
estimated  as  increased  from  four  to  ten  parts  per  1000.  The  blood  plates 
have  been  reported  as  much  more  abundant  than  normal.  In  most  cases 
the  leucocytes  are  increased,  numbering  perhaps  twenty  to  forty  thousand 
per  c.mm.  The  increase  occurs  especially  in  relation  to  the  large  multi- 
nucleated neutrophiles,  and,  to  a  less  extent,  the  large  uninucleated 
corpuscles.  The  eosinophiles  and  the  small  uninucleated  corpuscles,  on 
the  other  hand,  are  diminished.  The  condition  of  leucocytosis  appears 
early,  and  continues  throughout  the  fever,  passing  away  gradually  after 
defervescence  has  occurred.  It  is  believed  that  the  non-appearance  of 
leucocytosis  is  a  bad  indication.  Difference  of  statement  occurs  as  to  the 
spleen.  In  some  instances  it  may  certainly  be  determined  as  enlarged, 
while  more  frequently  there  is  no  appreciable  change.  It  seems  a  point  of 
relatively  slight  importance,  and  in  most  cases  minute  investigation  of  this 
is  inadvisable. 

Nervous  phenomena  are  often  conspicuous.  Thus,  in  children  they 
may  overshadow  other  symptoms.  Ushered  in  by  headache,  vomiting,  and 
convulsions,  the  condition  may  lead  within  a  few  hours  to  loss  of  conscious- 
ness. These  features,  curiously  enough,  may  disappear  as  the  lung 
symptoms  become  more  evident.  In  adults,  nervous  disturbance  is  more 
frequently  associated  with  apical  localisation  of  the  pneumonia.  But  in  a 
considerable  proportion  of  cases,  independently  of  any  such  distribution, 
some  degree  of  delirium  occurs  during  the  course  of  the  disease,  and  is  to 
be  interpreted  as  the  direct  effect  of  the  toxine.  The  delirium  may  be 
associated  with  marked  elevation  of  temperature.  Or  there  may  be 
evidence  of  meningitic  and  other  central  complication,  dependent  on 
invasion  of  the  meninges  by  the  pneumococcus.  Proof  of  this,  about 
which  it  is  by  no  means  easy  to  be  assured  clinically,  has  been  established 
by  the  discovery  of  the  organism  in  the  cerebral,  and  also,  though  less 
frequently,  in  the  spinal  meninges.  In  alcoholic  subjects,  the  course 
of  pneumonia  is  coloured  by  a  preponderance  of  nervous  disturbance  of  all 
kinds,  more  particularly  by  a  noisy,  violent  delirium,  requiring  special  care. 
Lastly,  at  or  about  the  crisis,  many  patients  suffer  from  a  low  muttering 
delirium,  which  may  closely  resemble  the  delirium  of  acute  alcoholism, 
although  there  is  no  causal  relationship  of  that  nature.  Doubtless  the 
intense  circulatory  enfeeblement  is  in  part  responsible  for  this.     When 


ACUTE  PNEUMONIA.  235 

head  symptoms  predominate  in  one  or  other  form,  the  condition  is  some- 
times described  as  cerebral  pneumonia.  Apart  from,  or  accompanying, 
these  graver  manifestations,  tremors  and  irregular  twitching  of  muscles 
are  common  enough.     The  knee-jerk  may  be  found  to  be  lost. 

The  digestion  is  commonly  much  disturbed.  As  in  other  fevers,  there 
is  apt  to  be  anorexia.  It  is  one  of  the  most  gratifying  indications  in  the 
course  of  pneumonia  when  the  patient  is  able  to  take  regular  and  sufficient 
supplies  of  nourishment.  The  tongue  is  usually  heavily  coated  with  a  grey 
white  fur,  the  edges  perhaps  remaining  red.  Sometimes  it  becomes  dry 
and  hard,  with  cracking  of  the  lips — the  typhoidal  tongue.  This  is  not  a 
welcome  appearance.  Vomiting  may  usher  in  the  attack,  especially  in 
children  and  old  subjects.  Abdominal  pain  may  be  complained  of,  in  some 
cases  due  to  intractable  tympanites.  The  bowels  tend  to  be  constipated, 
but,  on  the  other  hand,  diarrhoea,  even  dysenteric  in  type,  may  supervene. 
A  trace  of  jaundice  is  commonly  present,  and  may  be  observed  as  one  of 
the  earliest  of  superficial  changes.  Those  disturbances  of  the  alimentary 
tract  may  be  conspicuous  for  days  before  there  is  evidence  of  lung  disease. 
Perhaps,  like  the  graver  nervous  manifestations,  they  are  to  be  attributed 
to  the  direct  influence  of  the  pneumococcus  on  the  digestive  organs. 

The  urine  is  concentrated,  of  high  colour,  and  yields  a  copious  sediment 
of  urates.  It  is  frequently  albuminous,  apart  from  evidence  of  complicating 
nephritis.  This  is  doubtless  the  effect  of  the  organism  on  the  kidney,  as 
albuminuria  occurs  with  greater  constancy  in  this  than  in  most  other 
fevers.  There  is  conspicuous  diminution,  or  even  arrest,  of  the  discharge 
of  chloride  of  sodium  during  the  pyrexic  stage,  with  reappearance  in  excess 
during  resolution.  The  percentage  excretion  of  urea  is  increased  through- 
out, and,  conspicuously  about  the  crisis,  the  amount  discharged  is  absolutely 
increased.  Uric  acid  is  similarly  increased.  If  the  patient  happen  to  be 
diabetic,  there  is  a  striking  diminution  in  the  secretion  of  glucose.  This 
must  not,  however,  be  interpreted  in  the  patient's  favour. 

Approximately,  50  per  cent,  of  pneumonic  patients  present  herpes 
labialis.  It  occurs  usually  quite  early  in  the  illness.  Herpetic  eruptions 
elsewhere  are  much  less  frequent.  It  is  rightly  believed  that  a  good 
display  of  herpes  is  a  favourable  symptom.  Flushing  of  the  face  is  some- 
times more  marked  on  one  side  than  the  other.  Some  patients  sweat 
considerably  from  time  to  time  during  the  pyrexic  stage,  without  apparently 
much  relief  from  the  pungency  of  the  heat.  The  critical  fall  is  generally 
associated  with  marked  sweating.  Accompanying  the  diaphoresis,  various 
sweat  eruptions  may  appear.  More  rarely,  acne,  urticaria,  furuncles,  and 
ecchynioses  have  been  recorded. 

Inflammatory  affections  of  joints,  with  effusion,  occur  occasionally,  and 
have  been  attributed  to  the  invasion  of  the  joint  by  the  pneumococcus. 
Similarly,  painful  affections  of  bones  and  periosteum  are  described. 

Physical  signs. — These  are  variable,  both  in  character  and  date  of  appear- 
ance. In  some  cases  there  are  really  no  definite  signs  throughout  the 
whole  course.  In  others,  the  signs  develop  in  more  marked  fashion  com- 
paratively late  in  the  course  of  pneumonia,  perhaps  even  about  the  date  of 
crisis,  and  continue  for  a  considerable  time  thereafter.  This  occurs  in 
adults  sometimes,  but  often  in  children.  In  the  larger  proportion  of  cases 
some  of  the  signs  to  be  detailed  are  determinable  at  one  stage  or  another. 
But  the  more  experienced  the  observer,  the  less  is  he  likely  to  insist  on 
having  the  complete  picture  in  a  given  case. 

Inspection  may  reveal,  in  addition  to  the  unusual  movement  of  the  alee 


236  GENERAL  DISEASES. 

nasi  and  the  hurried  respiration,  limitation  of  movement  over  one  side. 
This  may  sometimes  be  visible  while  the  night-dress  is  undisturbed.  The 
limitation  of  movement  becomes  more  evident  on  palpation.  Sometimes  a 
pleural  rub  is  felt.     The  vocal  fremitus  may  be  recognised  as  increased. 

Percussion  in  most  cases  yields  some  degree  of  dulness.  Usually  this 
can  be  elicited  early.  When  the  consolidation  lies  deeply,  it  may  be 
obscured,  or  there  may  be  a  delay  of  some  days  before  it  is  certainly 
recognisable.  Quite  as  characteristic,  and  sometimes  determinable  before 
the  dulness,  is  tympanites,  some  degree  of  which  generally  accompanies  the 
dulness.  Tympanites  may  be  frequently  determined  in  front,  while  the 
major  dulness  is  behind,  or  the  tympanitic  area  may  be  situated  vertically 
higher  in  the  lung.  Often  the  physician  has  to  rest  his  physical  diagnosis 
— more  particularly  at  the  early  stage — rather  on  the  tympanitic  than  the 
dull  percussion  sound.  As  the  consolidation  advances,  dulness  becomes 
more  evident,  but  still  with  a  tympanitic  ring  in  the  surrounding  parts. 
Still  later,  when  the  dulness  clears  away,  the  tympanitic  element  often 
conspicuously  recurs. 

The  auscultatory  phenomena  vary  greatly  with  the  stage  and  extent  and 
situation  of  the  pneumonic  consolidation.  At  the  commencement,  breath 
sounds  may  be  enfeebled  over  a  limited  area,  and  this  may  be  alL  Or,  on 
the  contrary,  breath  sounds  may  be  harsher  than  normal,  gradually 
approximating  the  bronchial  type.  In  the  more  regular  cases,  after  the 
first  day  or  two,  a  harsh,  high  -pitched  variety  of  bronchial  breathing — 
conveniently  termed  tubular  —  is  the  rule.  The  bronchial  quality  of 
breathing  often  continues  for  long  after  the  critical  fall  of  temperature. 
Quite  early  the  inspiratory  sound  is  accompanied  by  comparatively  fine 
crepitations  (crepitatio  indux).  In  cases  where  there  is  an  inflammatory 
condition  of  bronchial  tubes,  coarse  accompaniments  may  mingle  with  or 
even  obscure  these.  The  crepitations,  in  most  instances,  are  heard  over  a 
gradually  widening  area.  In  a  day  or  two  they  may  disappear,  and  the 
harsh  tubular  breathing  be  unaccompanied.  Still  later — often  after  the 
crisis — crepitation  reappears  {crepitatio  redux),  along  with  coarser,  bubbling, 
even  consonating  accompaniments.  The  vocal  resonance  is  usually 
increased  at  the  time  when  the  other  indications  of  lung  consolidation  are 
present,  and  may  have  an  gegophonic  clang  over  the  tympanitic  area. 
With  regard  to  all  these  physical  signs,  it  is  to  be  borne  in  mind  that  they 
necessarily  diminish  in  intensity  as  one  passes  from  the  centre  of  more 
complete  consolidation  to  the  healthier  portions  of  lung  tissue. 

The  presence  of  complications  may  considerably  modify  the  physical 
signs.  When,  for  example,  pleural  effusion  is  present,  the  change  in  the 
physical  condition  of  the  parts  will  necessarily  alter  the  signs,  and  the 
result  may  be  a  rather  confused  picture,  in  which  the  signs  of  one  or  other 
condition  may  predominate.  The  final  recognition  of  the  effusion  is  often 
made  as  the  result  of  exploratory  puncture,  which  is  safe  practice  even  in 
presence  of  pneumonia.  Dry  pleurisy  is  so  essentially  part  of  an  acute 
pneumonia,  that  it  requires  no  separate  consideration. 

The  occurrence  of  abscess  or  gangrene,  which  is  rare,  will  be  suggested 
by  certain  symptoms  and  signs,  which  are  discussed  under  the  appropriate 
head.  Examination  of  the  heart  sometimes  shows  enlargement  of  the 
right  side.  The  heart  sounds  are  heard  with  unusual  loudness  over  the 
affected  side  of  the  thorax.  Early  in  the  attack  there  may  be  an  audible 
accentuation  of  the  second  sound  in  the  pulmonary  area.  Later,  this  may 
disappear.     Sometimes  murnmis  develop  in  relation  to  the  heart,  more 


ACUTE  PNEUMONIA.  237 

1 

especially  far  on  in  the  illness,  which  pass  away  as  the  patient's  condition 
improves. 

Varieties. — Eeference  has  been  made  incidentally  to  a  number  of  these. 
Thus  we  have  seen  that  pneumonia  in  children  differs  in  many  of  its 
features  from  the  adult  type.  Nervous  phenomena  (headache,  convulsions, 
delirium,  coma)  are  conspicuous.  The  temperature  tends  to  run  high,  and 
the  apex  is  more  commonly  affected.  On  the  other  hand,  in  senile 
pneumonia  the  temperature  tends  to  be  much  lower,  and  circulatory 
embarrassment  out  of  proportion  to  the  apparent  extent  of  lung  mischief. 

By  cerebral  pneumonia,  as  the  name  suggests,  is  meant  that  variety  of 
pneumonia,  whether  occurring  in  adults  or  children,  in  which  head 
symptoms  predominate.  The  name  latent  or  larval  'pneumonia  has 
been  applied  to  a  group  of  cases  in  which  slight  or  passing  symptoms  are 
present  for  a  limited  time,  and  where  the  diagnosis  might  be  accepted  with 
hesitancy  were  it  not  for  the  occurrence  of  other  true  cases,  apparently  in 
epidemic  form,  in  the  same  neighbourhood,  as  for  example  in  barracks  or 
prisons.  Wandering  or  migratory  or  creeping  pneumonia  describes  a 
variety  frequently  enough  seen — a  considerable  number  of  post-influenzal 
cases  in  the  Edinburgh  district  were  of  this  type — in  which  different  areas 
of  lung  tissue,  separate  or  continuous,  become  successively  involved.  The 
determination  of  such  cases  by  physical  signs  is  sometimes  difficult.  In 
double  pneumonia  we  have  the  approximately  concurrent  involvement  of 
portions  of  both  lungs,  with  correspondingly  greater  disturbance  of  hsema- 
tosis  and  circulatory  strain. 

Aside  from  such  convenient  enough  terms,  the  attempt  has  been 
countenanced  by  some  observers  to  separate  a  sthenic  and  an  asthenic  or 
adynamic  variety.  This  is  an  unsatisfactory  way  of  stating  that  the 
manifestations  of  the  pneumonic  fever,  as  of  other  fevers,  differ  according 
to  the  constitution  and  previous  health  of  the  person  attacked.  Similarly, 
we  may  safely  drop  from  present-day  nomenclature  such  varieties  as 
rheumatic,  malarial,  typhoidal.  The  acute  fever  is  one  and  the  same  in 
whomsoever  it  occurs,  and  such  subdivisions  tend  to  divert  the  mind  of 
the  observer  from  this  fundamental  conception.  As  in  other  acute  fevers, 
patients  sometimes  fall  into  that  low  reactionless  state  which  for  con- 
venience has  been  termed  the  typhoidal  state,  but  that  is  no  sufficient 
reason  for  speaking  of  a  typhoidal  variety.  We  have  already  seen  that 
when  pneumonia  attacks  a  diabetic  subject,  it  has  certain  peculiarities,  and 
tends  to  lead  to  death — it  may  be  with  gangrene  or  abscess — but  we  are 
not,  therefore,  to  describe  a  diabetic  pneumonia  as  something  distinct. 

Complications  and  sequelae. — It  is  to  be  premised,  in  the  first 
place,  that  many  phenomena  which  formerly,  when  pneumonia  was 
regarded  as  a  local  inflammation  of  lung,  were  described  as  complications, 
are  to  be  regarded  as  an  expression  of  the  invasion  of  the  different  organs 
by  the  morbific  microbe.  There  is  abundant  post-mortem  evidence  for  this 
way  of  stating  the  case.  A  number  of  these  so-called  complications  have 
been,  therefore,  included  in  the  preceding  description  of  the  clinical 
features.  It  is.  convenient,  however,  that  reference  should  be  made  once 
more  to  some  of  these. 

Taking  the  respiratory  organs  first,  some  degree  of  pleurisy  forms  a 
regular  part  of  the  disease  (pleuro-pneumonia).  But  the  pleurisy  may  be 
more  considerable,  and  effusion  occur  either  into  the  sac  of  the  same  or  of 
the  other  side.  In  the  fluid  collection  the  pneumococcus  has  been  dis- 
covered.    Eeference  has  already  been  made  in  dealing  with  the  physical 


238  GENERAL  DISEASES. 

signs  to  the  difficulty  of  separating  pleurisy  with  effusion  from  pneumonia. 
Empyema  sometimes  develops  in  the  wake  of  pneumonia,  still  further 
confusing  the  diagnosis,  which  in  such  cases  must  rest  ultimately  on 
exploratory  puncture.  The  empyema  becomes  evident  in  some  cases  only 
after  the  pneumonic  phenomena  have  disappeared.  There  is  reason  for 
supposing  that  a  precedent  pneumonia  is  a  commoner  cause  of  empyema 
than  was  believed  formerly.  The  clinical  features  of  empyema  are  con- 
sidered in  their  proper  place.  Diffuse  suppuration  may  sometimes  replace 
resolution,  the  patient  tumbling  into  a  typhoidal  condition,  from  which  he 
does  not  recover.  Or  abscess  or  gangrene  of  the  lung  may  result.  The 
symptoms  and  signs  of  these  conditions  are  discussed  in  due  course.  Both 
are  rare  complications.  The  latter  occurs  more  frequently  in  alcoholic 
subjects.  Bronchitis  may  precede  or  attend  the  attack,  and  tends  to 
aggravate  the  dyspnoea  from  which  the  patient  suffers,  and  complicate  the 
physical  signs.  Lastly,  there  is  usually  described  a  badly-resolving 
pneumonia,  with  persistent  chronic  infiltration.  With  regard  to  this 
there  has  been  a  good  deal  of  discussion.  It  has  been  maintained  that  an 
acute  pneumonia  may  fail  to  clear  up,  leaving  a  permanent  residuum  of 
consolidated  lung,  which  may  become  tuberculous.  It  is  to  be  remembered, 
however,  that  in  many  such  cases  no  opportunity  was  available  for  the 
examination  of  the  lungs  of  the  patient  before  the  acute  attack.  Were 
this  possible,  the  probability  is  that  in  many  instances  a  pre-existing 
infiltration  would  be  determined,  the  pneumonic  process  attacking  more 
readily  the  damaged  lung.  Again,  there  is  much  reason  for  believing  that 
in  some  instances  the  process  is  throughout  tuberculous,  and  that  the 
appearances  of  the  acuter  stage  have  led  erroneously  to  the  diagnosis  of 
an  acute  pneumonia. 

Circulatory  complications  are  not  very  common  apart  from  the  more 
general  circulatory  disturbance,  which  has  been  described  already.  Endo- 
carditis is  perhaps  the  most  frequent.  It  may  be  either  simple  or 
ulcerative.  Some  25  per  cent,  of  the  recorded  cases  of  ulcerative 
endocarditis  have  been  etiologically  related  to  pneumonia.  The  diagnosis 
will  necessarily  rest  on  the  development  of  a  murmur  during  the  course  of 
the  acute  attack.  Pericarditis  occurs  in  a  fair  number  of  cases,  especially 
in  double  pneumonia  or  extensive  involvement  of  the  left  side,  and  more 
frequently  in  children  than  adults.  It  may  be  either  dry  pericarditis,  or 
accompanied  by  serous  or  occasionally  purulent  effusion.  The  diagnosis  is 
not  always  possible,  but  may  be  suggested  by  increasing  faintness  of  heart 
sounds  and  further  prejudice  of  the  circulation.  On  the  whole,  it  is  a  less 
serious  complication  than  a  priori  might  be  anticipated.  Thrombic 
conditions  of  veins  and  embolism  of  arteries  occur  occasionally. 

It  has  been  pointed  out  how  largely  nervous  symptoms  bulk  in  certain 
cases.  In  addition  to  these,  true  meningitis — dependent  on  the  invasion 
of  the  meninges  by  the  pneumococcus — occurs  from  time  to  time.  It 
appears  most  generally  during  the  pyrexic  period,  and  may  be  accordingly 
missed,  unless  paralytic  phenomena  appear.  Hemiplegia  may  supervene 
without  traceable  lesion,  as  described  by  several  competent  observers. 
Neuritis  has  also  been  reported. 

Gastro-intestinal  complications  of  different  kinds  occur.  Some  degree 
of  icteric  tinge  is  so  common  that  it  may  almost  be  regarded  as  part  of  the 
pneumonic  fever.  Actual  jaundice  occurs  in  a  smaller  proportion  of  cases, 
being  apparently  commoner  in  right- sided  pneumonia.  It  may  develop  at 
any  period  of  the  attack,  but  appears  most  commonly  about  the  third  or 


ACUTE  PNEUMONIA.  239 

fourth  day.  The  explanation  of  the  jaundice  is  not  quite  clear.  A  painful 
gastritis  may  be  present,  and  occasionally  a  croupous  colitis,  with  resultant 
diarrhoea.  Parotitis,  tending  to  pass  on  to  suppuration,  is  one  of  the  rarer 
complications.  It  has  been  observed  sometimes  in  cases  where  ulcerative 
endocarditis  has  appeared.     In  most  instances  it  is  of  evil  omen. 

Keference  has  been  made  already  to  the  frequency  of  albuminuria. 
Actual  nephritis  is  not  a  common  complication.  The  arthritic  condition 
which  has  already  been  described  used  to  be  regarded  as  a  complication. 
Since  the  determination  of  the  organism  in  the  effusion,  it  is  perhaps  better 
regarded  as  one  of  the  less  common  manifestations  of  the  disease.  It  may 
supervene  during  the  pyrexic  stage  or  after  the  critical  fall. 

Diagnosis. — In  the  majority  of  instances  diagnosis  is  not  difficult. 
When,  along  with  many  of  the  symptoms  of  an  acute  fever,  the  physical 
condition  of  consolidation  is  discoverable,  there  is  little  room  for  doubt. 
But  it  must  be  borne  in  mind  that  a  fair  number  of  cases  of  pneumonia 
occur  without  traceable  or  at  least  characteristic  physical  signs,  and  that 
cases  occur  also  in  which  the  nhysical  signs  of  pneumonia  are  present  with- 
out anything  else. 

In  concluding  a  diagnosis,  attention  will  be  directed  especially  to  the 
following  points : — The  general  appearance  of  the  patient,  his  more  or  less 
flushed  face,  increased  respiration  out  of  proportion  to  pulse  rate,  activity 
of  the  alse  nasi,  rapidly  occurring  and  high  degree  of  pyrexia  (attaining 
its  maximum  it  may  be  within  thirty-six  or  forty-eight  hours),  the  expec- 
toration and  the  history  of  acute  onset,  with  rigor  or  convulsion,  and 
frequently  pain  in  the  side.  The  significance  of  these,  more  particularly 
the  pyrexia,  is  necessarily  less  in  the  child  than  the  adult.  In  the  former, 
sudden  and  high  degrees  of  pyrexia  are  determined  by  many  less  serious 
lesions.  In  addition  to  such  manifestations,  the  absence  of  early  symptoms, 
characteristic  of  other  acute  processes,  as,  for  example,  the  sore  throat  or 
rash  of  scarlatina,  has  negative  value  of  importance.  In  some  instances 
the  appearance  of  a  herpes  may  bear  corroborative  import.  If,  along  with 
such  symptoms,  one  or  two  of  the  more  obvious  physical  signs  are  present, 
the  diagnosis  should  be  complete.  Of  physical  signs  at  an  early  stage, 
tympanites  is  to  be  looked  on  with  no  less  suspicion  than  dulness.  Limited 
areas  of  enfeebled  breathing,  with  perhaps  a  faint  crepitation  on  inspiration, 
or  of  conspicuously  whiffing,  bronchial  breathing,  or  of  increased  vocal 
resonance,  are  of  the  utmost  diagnostic  value. 

Eeal  difficulty  seldom  exists  with  reference  to  pneumonia  as  occurring 
in  a  previously  healthy  adult.  Mistakes  are  more  likely  from  omission  in 
patients  already  weakened  by  disease,  as  for  example  when  pneumonia 
supervenes  as  a  complication  of  one  of  the  acute  fevers,  or  of  some  other 
lung  process,  or  of  such  chronic  diseases  as  diabetes,  kidney  and  heart 
disease,  tuberculosis,  or  cancer,  or  after  surgical  operation.  In  any  of  these, 
an  exacerbation  of  pyrexia,  without  other  explainable  cause,  ought  to  lead 
the  physician  to  a  careful  scrutiny  of  this  possibility.  Similarly,  in  the 
case  of  acute  alcoholism  or  other  delirious  conditions  without  certain  cause, 
it  is  good  practice  to  make  a  point  of  excluding  pneumonia.  As  has  been 
pointed  out  already,  there  is  a  frequent  relationship  between  delirium 
tremens  and  pneumonia. 

In  the  case  of  children  a  double  difficulty  is  encountered.  On  the  one 
hand,  from  the  preponderance  of  nervous,  more  particularly  head  symptoms 
and  other  constitutional  distress,  the  advent  of  cerebral  mischief,  e.g. 
meningitis,  or  of  one  of  the  acute  fevers,  e.g.  scarlatina,  may  be  supposed. 


24o  GENERAL  DISEASES. 

On  the  other  hand,  the  clear  determination  of  physical  signs  is  often  harder 
in  the  child ;  the  actual  examination  is  more  difficult,  and  the  physical 
signs  of  different  conditions  are  less  clearly  separable  than  in  the 
adult.  Thus  it  comes  about  that  uncertainty  may  be  experienced  in  dis- 
tinguishing between  croupous  pneumonia  and  broncho-pneumonia  or  even 
pleurisy  with  effusion.  The  diagnosis  will  finally  be  made  by  a  careful 
estimate  of  the  preponderance  of  evidence  along  the  lines  already  suggested. 

In  every  case,  it  must  be  borne  in  mind  that  pneumonia  may  be  present 
along  with  some  other  constitutional  condition  or  preliminary  lesion. 
Reference  has  already  been  made  to  the  frequency  with  which  pneumonia 
supervenes  on  certain  constitutional  affections.  It  is  equally  important  to 
bear  in  mind  that  pneumonia  may  develop  in  connection  with  bronchitis, 
as  in  a  considerable  number  of  instances,  or  in  relation  to  tuberculosis,  as 
has  been  already  described. 

It  may  be  convenient  to  rehearse  that  of  diseases  other  than  pulmonary, 
with  which  pneumonia  is  likely  to  be  confused,  the  most  important  are 
meningitis,  typhoid,  typhus,  general  tuberculosis,  septicemia  (especially  in 
old  subjects),  and  perhaps  scarlatina  (in  the  young).  Of  pulmonary 
diseases  with  which  it  might  be  confused,  the  most  noteworthy  are  capillary 
bronchitis,  broncho-pneumonia,  acute  tuberculosis,  pleurisy,  empyema 
(especially  in  the  child).  It  is  not  the  regular  cases  of  pneumonia  which 
are  likely  to  cause  difficulty,  but  cases  aberrant  from  the  classic  type,  either 
at  the  commencement — as  the  pneumonia  of  old  subjects,  which  starts  in- 
sidiously ;  or  of  children,  presenting  exaggerated  nervous  disturbance ;  or 
aberrant  throughout  their  course,  as  when  the  typhoidal  state  supervenes ; 
or  aberrant  as  regards  distribution,  e.g.  wandering  pneumonia  ;  or  as  regards 
physical  signs.  The  diagnosis  of  complicating  affections  has,  for  the 
present,  been  sufficiently  considered,  and  is  further  dealt  with  under  the 
several  appropriate  headings. 

Prognosis. — The  prognosis  is  generally  grave.  The  mortality  of 
pneumonia  varies  much  in  different  statistics,  but  at  the  best  it  is 
sufficiently  high  to  make  the  prognosis  an  anxious  one.  Taking  for  our 
basis  of  calculation  the  collective  statistics  of  various  observers  in  many 
countries,  we  may  fix  14  to  20  per  cent,  as  the  death-rate.  The  mortality 
fluctuates  much  in  different  places  and  at  different  times. 

The  character  and  course  of  the  disease  varies  much'  with  the  seasons, 
and  the  prognosis  in  a  given  case  may  be  fairly  influenced  by  the  character 
of  precedent  cases,  about  the  same  time  and  in  the  same  neighbourhood. 

The  immediate  prognosis  is  determined  in  all  cases  by  a  consideration 
of  the  pulse  and  heart  from  day  to  day  and  hour  to  hour,  rather  than  by 
the  temperature  or  the  lung  condition.  The  heart  suffers  directly  from  the 
pyrexia,  as  in  other  fevers ;  and  the  consolidation  of  so  large  an  area  of  lung 
tissue  puts  an  extra  strain  on  the  heart  in  a  variety  of  ways.  Further, 
there  is  reason  to  assume  that  the  toxines  act  with  especial  prejudice  on 
the  circulatory  organs.  Advancing  softness  of  the  pulse  is  ground  for 
most  careful  watching.  Marked  dicrotism  justifies  considerable  anxiety. 
A  pulse,  palpably  influenced  by  slight  natural  movements,  such  as  that  of 
inspiration,  or  by  coughing,  is  a  grave  indication.  A  feeble  and  irregular 
pulse,  hardly  countable  at  the  wrist,  is  of  bad  omen. 

The  prognosis  is  influenced  much  by  the  condition  and  constitution 
of  the  patient.  Thus  it  is  more  grave  in  patients  after  middle  life. 
In  previously  healthy  adults  it  is  much  more  favourable.  In  other- 
wise healthy  children,   it   is   still  more   so.      In   constitutionally  feeble 


ACUTE  PNEUMONIA.  241 

subjects,  more  particularly  at  the  two  extremes  of  life,  the  prognosis  is 
bad. 

The  disease  is  less  common  in  the  female  sex,  but  when  it  occurs  the 
outlook  is  less  favourable.  Female  mortality  is  distinctly  higher.  The 
prognosis  in  pregnancy  is  very  grave,  though  death  does  not  certainly  follow. 
Abortion  is  apt  to  be  induced,  sometimes  with  alarming  haemorrhage. 

Certain  precedent  illnesses  are  conspicuously  prejudicial,  for  example, 
influenza.  During  the  recent  epidemic  of  influenza  this  was  frequently 
remarked.  Patients  too  often  succumbed,  not  to  the  influenza,  but  to  the 
complicating  pneumonia.  Alcoholic  individuals  make  bad  subjects  for 
pneumonia,  and  the  prognosis  is  correspondingly  graver.  The  presence  of 
chronic  disease  of  heart,  or  kidney,  or  other  organ  adds  much  to  the  gravity. 
In  the  case  of  diabetics  who  are  attacked  by  pneumonia,  the  prognosis  is 
most  unfavourable.  The  amount  of  glucose  excreted  falls  quickly,  and  it 
may  be  thought  the  patient  is  doing  well.  But  comparatively  suddenly  he 
may  die  of  circulatory  failure. 

The  local  distribution  of  the  affection  is  not  unimportant.  Thus  a 
double  pneumonia,  cceteris paribus,  warrants  a  more  serious  prognosis.  Even 
here  the  issue  is  far  from  being  certainly  fatal.  Apical  pneumonia  seems 
more  fatal  than  basal.  A  good  appetite  and  continued  power  of  assimila- 
tion are  most  satisfactory  indications.  An  abundant  eruption  of  herpes 
facialis  may  be  looked  on  with  favour.  Absence  of  leucocytosis  has  been 
interpreted  unfavourably.  A  rapid  increase  of  the  small  uninucleated 
corpuscles,  and  the  reappearance  of  the  eosinophiles  occurring  about  the 
crisis,  would  seem  to  point  to  a  satisfactory  termination. 

The  occurrence  of  complications  renders  the  danger  more  imminent;. 
Thus  the  supervention  of  oedema,  as  evidenced  by  the  appearance  of  a  watery, 
so-called  prune-juice  expectoration,  already  described,  is  of  bad  import. 
The  appearance  of  foetor  of  breath  and  foetid  expectoration,  pointing  to 
gangrene,  is  most  unfavourable.  The  prognosis  of  abscess  of  the  lung  is 
discussed  more  fully  under  a  separate  head. 

Treatment. — The  treatment  of  pneumonia  should  be  guided  by  the 
principles  which  are  applicable  in  the  conduct  of  other  kinds  of  acute  fever. 
The  more  fully  this  conception  is  before  the  physician,  in  approaching  a 
given  case,  the  better  for  the  patient.  The  pneumonic  fever  is  a  short, 
acute  fever,  with  a  liability  to  certain  accidents,  more  especially  circulatory 
failure.  Its  treatment  is  that  of  an  acute  fever,  with  a  jealous  guard  over 
the  heart.  The  finger  on  the  pulse  is  the  better  instrument  than  the 
stethoscope  over  the  lungs.  Treatment  divides  itself  naturally  into  two 
sections : — 

1.  Prophylactic. — This  aspect  of  the  treatment  of  pneumonia  is 
warranted  by  the  occurrence  of  the  disease  in  epidemic  form.  So  many 
instances  of  this  have  been  reported  in  workhouses,  prisons,  and  other 
institutions,  on  board  training-ships,  and  even  in  private  dwellings,  that  the 
duty  of  disinfection  must  be  apparent.  The  well-known  example  of  the 
Bavarian  prison  at  Amberg  is  especially  trenchant.  During  the  first  five 
months  of  1880,  out  of  1150  prisoners,  no  less  than  161  were  attacked  by 
pneumonia,  and  of  these  forty-six  died.  Another  severe  epidemic  occurred  in 
the  same  prison  within  ten  years.  Further,  there  was  isolated  from  the  floor 
of  the  prison,  an  organism  apparently  identical  with  the  pnemnococcus — 
though  this  is  not  quite  clear — and  the  disease  was  reproduced  by  inocula- 
tion. The  same  organism  has  been  discovered  in  other  badly-ventilated 
dwellings.  All  this  points  to  the  necessity  for  the  rigid  enforcement  of 
vol.  1. — 16 


242  GENERAL  DISEASES. 

hygienic  measures  in  the  building  and  ventilation  of  such  establishments, 
and  the  adoption  of  measures  for  disinfection  where  one  or  more  cases  have 
occurred.  There  is  similar  need  for  the  enforcement  of  rules  for  disinfec- 
tion of  the  expectoration.  There  is  sufficient  reason  for  the  belief  that  in 
the  past  we  have  been  too  lax  in  such  measures. 

2.  Therapeutic. — It  may  fairly  be  asked  whether,  with  all  our  know- 
ledge of  the  actual  cause  of  the  disease,  we  are  f urther  forward  in  this  aspect 
of  treatment.  Awkwardly  enough,  the  mortality  from  pneumonia  has  not 
fallen  coincidently  with  the  advance  of  our  knowledge.  Still  this  must 
not  be  held  to  deprive  of  significance  the  recent  therapeutic  endeavours 
based  on  the  etiological  fact.  If  the  organism  is  the  actual  cause  of  the 
disease,  and  prophylactic  measures  have  failed  to  prevent  its  entrance,  the 
organism  must  be  opposed  within  the  body.  This  may  be  attempted 
theoretically  in  one  of  two  ways.  Either  we  may  seek  to  destroy  the 
organism  directly,  or  we  may  antagonise  those  products  of  its  growth  and 
development  which  are  toxic  to  the  patient. 

The  endeavour  has  been  made  to  realise  the  first  purpose  by  intra- 
tracheal injections,  e.g.  of  naphthol,  by  intrapulmonary  injections  (directly 
into  the  consolidated  area),  e.g.  of  perchloride  of  mercury,  and  by  inhalations 
of  certain  volatile  agents,  e.g.  iodide  of  ethyl.  Up  to  the  present  the  results 
have  not  been  so  completely  satisfactory  as  to  justify  the  recommendation 
of  one  or  other  method.  Still  they  have  not  been  so  discouraging  as  to 
forbid  the  possibility  of  future  success  along  such  lines. 

The  second  conception,  namely,  that  of  antagonising  the  products  of  the 
organism,  has  been  elaborated  by  a  number  of  observers.  We  have  already 
seen  that  the  pneumococcus  probably  affects  the  system  through  the  pro- 
duction of  a  poisonous  albumin.  The  so-called  pneumotoxine  presumably 
induces  pyrexia  and  other  grave  constitutional  disturbance,  until,  it  would 
appear,  there  is  produced  within  the  circulation  another  body  possessed  of 
antagonising  properties,  so-called  antipneumotoxine.  It  is  maintained 
that  immunity  can  be  conferred  on  an  animal — for  some  six  months — by 
the  introduction  into  a  vein,  or  subcutaneously,  of  the  glycerin  extract 
from  a  culture,  or  of  the  filtered  culture  itself.  It  would  seem  that  the 
serum  of  such  immunised  animals  can  in  turn  confer  immunity  on  other 
animals,  and,  what  is  of  still  greater  practical  moment,  can  arrest  the 
disease,  if  injected  sufficiently  early  after  infection.  It  has  been  shown 
also  that  the  seruin  of  patients  suffering  from  pneumonia — removed  shortly 
after  the  crisis — possesses  this  immunising  and  curative  property  in  respect 
of  inoculated  animals.  Encouraging  results  have  also  been  reported  in  the 
human  subject.  Thus  de  Eenzie  has  used  serum,  prepared  according  to 
Pane's  instructions,  since  1896,  in  grave  cases  of  pneumonia,  and  reports 
that  his  former  mortality  of  24  per  cent,  fell  under  the  treatment  to  9  per 
cent.  After  injection  of  a  sufficient  quantity  of  serum,  a  remarkable  fall 
of  temperature  occurred.  Often  enough  there  was  a  return  to  the  normal 
temperature,  which  was  maintained,  although  the  lung  process  continued 
determinable.  The  improvement  in  the  general  condition  of  the  patient 
-was  noteworthy,  although  the  clinical  progress  of  the  local  lesion  was  not 
apparently  modified. 

It  is  to  be  observed  that  Pane's  serum  appears  to  have  protective  powers 
against  certain  strains  or  varieties  of  pneumococcus  and  not  against  others. 

While  the  serum  method  can  hardly  be  reckoned  sufficiently  mature  to 
warrant  its  general  adoption,  there  is  reason  to  anticipate  a  satisfactory 
development  on  this  line  in  the  near  future. 


ACUTE  PNEUMONIA,  243 

Short  of  the  consummation  of  such  rational  methods,  we  have  to  fall 
back  on  general  principles  of  wider  application.  In  commencing  the  treat  • 
ment  of  pneumonia,  the  physician  will  do  well  to  think  of  it  less  as  a  lung 
dise'ase  than  as  an  acute  continued  fever  of  comparatively  short  duration. 
It  is  of  the  first  importance  that  the  patient  have  an  abundant  supply  of 
fresh  air.  A  draught  is  less  to  be  feared  than  the  close,  overheated  rooms 
in  which  pneumonia  is  often  treated.  The  morbid  dread  of  fresh  cold  is  a 
fatal  mistake  for  the  patient.  The  first  point  is,  therefore,  that  there  be  an 
abundant  and  direct  supply  of  fresh  air,  with  as  much  sunshine  as  possible. 
This  is  essential  in  all  fevers,  but  especially  so  in  a  fever  accompanied  by  a 
local  pulmonary  lesion,  which  robs  the  patient  of  a  large  area  of  oxygenating 
surface.  It  is  remarkable  sometimes  how  quickly  a  feeble,  depressed 
circulation  improves  by  the  correction  of  faulty  treatment  in  this  respect. 
And  such  results  are  always  attainable  without  the  access  of  the  much 
feared  draught. 

The  next  indication  is  to  husband  the  patient's  strength  with  vigilance, 
and,  in  particular,  to  guard  against  circulatory  failure.  The  dietary  should 
be  that  of  fever.  Eemarkable  differences  occur  in  respect  of  appetite  and 
power  of  assimilation.  One  patient  declines  everything  within  the  first 
day  or  two,  another  takes  milk  and  soups  almost  with  avidity.  In  the 
latter  case  there  will  be  little  difficulty,  and  ordinary  meal  hours  may  be 
adhered  to.  In  the  former,  measured  quantities  of  simple,  nutritious  fluid 
food  must  be  given  at  regular  intervals,  say  every  three  hours,  with  no  less 
care  than  drugs  are  exhibited.  Sometimes  a  grain  or  two  of  calomel,  or  a 
corresponding  amount  of  grey  powder,  makes  a  wonderful  improvement  in  a 
flagging  appetite. 

In  most  cases,  after  the  first  two  or  three  days,  alcoholic  stimulants  will 
be  found  helpful.  Of  these,  diluted  brandy  or  whisky  is  the  most  service- 
able. They  are  given  advantageously  along  with  milk — often,  best  of  all, 
with  boiled  milk — or  as  egg-flip,  or  with  tea  or  coffee.  Sometimes 
champagne  picks  up  the  patient  more  rapidly  and  efficiently.  The 
quantity  of  alcohol  will  vary  much.  In  less  urgent  cases  a  tablespoonful 
or  two  every  six  hours  may  suffice.  When  the  condition  is  more  serious, 
the  same  quantity  may  be  required  every  two  hours,  or  more  frequently. 
Some  patients  do  perfectly  well — possibly  even  better — without  alcohol 
throughout.  The  chief  guide  to  the  exhibition  and  the  dose  of  alcohol  is 
the  pulse.  It  is  when  the  full,  bounding  pulse  of  the 'first  day  or  two  is 
replaced  by  the  soft  and  approximately  dicrotic  beat,  that  stimulants  are 
indicated.  As  the  dicrotic  character  becomes  more  evident,  and  the  feeble, 
perhaps  irregular,  wave  comes  to  be  disturbed  by  each  movement  of  the 
patient — notably  by  each  cough — there  is  imperative  call  for  a  proportion- 
ate increase  in  the  frequency  and  quantity  of  alcoholic  stimulant.  Elderly 
and  obese  patients,  those  in  debilitated  condition,  and  especially  alcoholic 
subjects,  require  such  assistance  earlier,  and  in  larger  doses,  than  those  who 
have  been  previously  vigorous.  There  is  considerable  danger  in  withholding 
stimulants  from  the  alcoholic  class. 

Next  in  significance  to  alcohol  come  cardiac  tonics.  The  same  guid- 
ing rules  are  applicable  here.  During  the  first  two  or  three  days,  and 
in  simpler  cases  possibly  throughout,  these  may  be  unnecessary.  But  with 
advancing  prejudice  of  the  circulation,  as  evidenced  by  the  changes  in 
the  character  of  the  pulse  already  referred  to,  their  value  is  great.  The 
most  generally  helpful  is  strophanthus.  This  is  exhibited  conveniently  in 
say  10-minim  doses  of  the  tincture,  three  to  six  times  daily.     Digitalis  may  be 


244  .  GENERAL  DISEASES 

used  similarly,  although  the  former  seems,  as  a  rule,  preferable.  In  some 
instances,  strophanthus  may  be  helpful  combined  with  strychnine.  In  the 
presence  of  more  urgent  circulatory  failure,  the  more  frequent  adminis- 
tration of  strophanthus  is  indicated,  and  the  effect  may  be  hastened  by"  its 
subcutaneous  use  (strophanthin  T^-g-  gr.)  In  such  emergency,  greater  reliance 
is  to  be  placed  on  more  diffusible  stimulants,  such  as  ether,  camphor, 
caffeine,  by  subcutaneous  injection.  With  a  patient  in  extremis  from 
threatened  circulatory  failure  and  grave  dyspnoea,  this  treatment  may  be 
supplemented  by  the  exhibition  of  oxygen. 

The  relief  of  the  chest  pain  is  urgently  called  for  in  most  cases.  Its 
removal  improves  the  patient's  general  condition  marvellously,  and  indirectly 
relieves  the  respiratory  and  circulatory  distress.  To  this  end,  warm 
poultices,  turpentine  stupes,  or,  for  some  patients,  an  ice-bag  or  the  cold- 
water  coil — the  choice  will  depend  largely  on  the  patient — are  serviceable. 
In  some  instances,  particularly  in  powerful  and  plethoric  subjects,  local 
leeching  or  cupping,  dry  or  wet,  according  to  circumstances,  is  more  useful. 
Or  the  desired  effect  may  be  best  attained  by  the  subcutaneous  injection  of 
morphine,  in  the  absence  of  evident  contra-indication.  The  objection  some- 
times urged  against  its  administration,  on  the  score  of  interference  with 
expectoration,  lacks  pathological  support.  On  the  contrary,  the  use  of 
morphine  is  further  suggested  in  relation  to  the  harassing,  effectless  cough, 
which  unnecessarily  disturbs  the  patient's  rest  and  often  seriously  perturbs 
the  circulation.  Sanction  for  its  exhibition  is  afforded  by  the  cardiac 
condition.  The  drug  will  be  used  with  moderation,  and  discontinued  as  the 
necessity  diminishes. 

Eestlessness  and  sleeplessness  are  symptoms  which  require  the  utmost 
consideration.  Much  may  here  be  gained  by  attention  to  lightness  of 
bed-clothing,  coolness  of  the  sick-room,  and  the  free  entrance  of  fresh  air. 
I  have  seen  oxygen  cylinders  ordered  for  the  relief  of  a  patient,  while  the 
atmosphere  of  his  room  was  stifling  in  the  extreme — an  irrational  pro- 
ceeding surely !  Eemarkable  relief  from  restlessness  may  be  achieved  by 
the  careful  use  of  the  wet-pack,  which  may  be  complete  or  partial  accord- 
ing to  circumstances.  The  one  point  to  be  attended  to  is,  that  the  patient 
be  excluded  from  effort  of  any  kind  during  the  procedure.  If  this  be 
managed,  most  salutary  results  may  be  anticipated.  So  beneficial  in 
respect  of  restlessness  has  this  method  proved,  that  some  physicians  are 
strong  in  the  recommendation  of  tepid  baths,  from  which  it  is  reported 
that  even  better  results  are  obtained.  Personal  experience  does  not 
warrant  my  recommendation  of  the  method,  in  the  carrying  out  of  which 
there  must  always — at  least  in  private  practice — be  some  difficulty  in 
preventing  all  effort  on  the  part  of  the  patient.  In  addition  to  these 
simple  measures,  morphine,  in  the  moderate  dosage  which  has  been 
sanctioned  on  other  grounds,  may  exert  a  salutary  influence.  Chloral, 
say  15  or  20  grs.,  may  prove  of  the  greatest  service,  by  affording  a  few 
hours'  calm  sleep,  which  removes  the  restlessness  and  steadies  the  circula- 
tion as  nothing  else  can.  The  chloral  may  be  advantageously  combined, 
sometimes  with  a  claret-glassful  of  toddy.  Sulphonal  or  trional  may  be 
i  similarly  used,  especial  care  being  had  to  the  thorough  solution  of  the 
former  in  hot  diluted  spirit.  Such  a  dose  given  opportunely  would  some- 
times seem  to  be  the  determinant  of  the  critical  fall  of  temperature — the 
patient  waking  from  a  restful  sleep  with,  perhaps,  almost  normal  tem- 
perature. 

Of  antipyretics,  in  the  limited  sense,  there  is  seldom  need.     Hyper- 


TETANUS.  245 

pyrexia  is  not  a  clamant  symptom,  and  there  is  no  call  to  interfere  with  the 
ordinary  pyrexial  cycle.  The  simple  method  of  wet-packing  already 
referred  to  may  well  be  considered  in  relation  to  this.  Cold  baths  are 
seldom  indicated.  If  the  occasion  demand  the  use  of  drugs,  quinine  or 
antipyrine  will  be  found  the  most  trustworthy.  The  method  formerly 
much  in  vogue  of  commencing  the  treatment  of  pneumonia  with  aconite 
or  other  cardiac  depressant,  will  rarely  be  found  expedient,  and,  like  the 
classic  thorough-going  blood-letting,  is  in  most  cases  contra -indicated,  the 
full,  bounding  pulse  of  the  early  period  being  only  too  rapidly  replaced  by 
the  compressible  vessel.  In  some  cases,  considerable  relief  to  the  patient, 
without  counterbalancing  disadvantage,  is  obtained  by  the  free  exhibition 
of  the  liquor  ammonii  acetatis  from  the  first. 

Consideration  will  be  paid  to  unusual  symptoms  as  they  supervene, 
and  their  treatment  undertaken  in  the  light  of  the  indications  already 
premised,  due  regard  being  had  to  the  age  and  condition  of  the  patient. 
More  particularly,  the  occurrence  of  complications  and  sequelee,  such  as 
bronchitis,  empyema,  pulmonary  abscess,  gangrene,  nephritis,  delirium 
tremens,  must  be  recognised  and  met  as  speedily  as  possible.  The  actual 
treatment  necessary  in  different  cases  must  vary,  and  is  considered  in 
•detail  under  the  appropriate  head. 

During  convalescence  certain  tonics  prove  helpful,  according  to  the 
condition  of  the  patient,  such  as  quinine,  iron,  strychnine,  arsenic,  cod-liver 
oil.  Alcohol  plays  a  useful  part  in  this  direction,  whether  it  has  been 
necessary  earlier  or  not.  About  the  critical  fall,  and  for  some  time  there- 
after, wine  or  light  beer  will  prove  of  service.  The  length  of  time  the 
patient  is  to  be  kept  in  bed  depends  upon  the  constitution  of  the  patient, 
the  state  of  the  circulation,  and  the  local  condition.  There  is  much 
irregularity  in  the  rate  of  improvement  in  different  cases,  conspicuously  so 
as  regards  pulmonary  signs.  Here,  too,  the  pulse  is  a  better  gauge  than 
the  local  signs.  When  convalescence  is  sufficiently  established,  there  is 
nothing  to  be  gained  by  prolonged  confinement  of  the  patient.  On  the 
contrary,  convalescence  is  often  remarkably  hastened  by  a  change  to  the 
country.  The  choice  of  such  change  will  depend  on  the  residence,  con- 
stitution, tastes,  and  purse  of  the  patient.  Having  regard  to  the  liability 
to  recurrence,  the  physician  must  see  that  the  cure  is  made  as  thorough  as 
possible,  and  all  rational  lines  of  prophylaxis  followed  in  future. 

E.  W.  PHILIP. 


TETANUS. 
Syn.,  Fr.,  Tetanos ;  Ger.,  Starrkrampf. 

Tetanus  is  a  specific  infective  disease,  due  to  the  presence  and 
multiplication  of  the  bacillus  of  tetanus,  characterised  by  an  affection  of 
the  central  nervous  system,  which  gives  rise  to  persistent  tonic  spasms, 
with  brief  violent  exacerbations. 

History. — Carle  and  Eattone  were  the  first  to  show  that  tetanus  was 
transmissible  from  man  to  animals,  and  hence  of  an  infective  nature. 
Mcolaier  in  1885  was  able  to  cultivate  the  organism  in  impure  form 
outside  the  animal  body,  and  with  these  cultures  was  able  to  set  up  in 
rabbits,  guinea-pigs,  and  mice  a  disease  apparently  identical  with  tetanus 
in  man.  He  was  also  able  to  show  that  small  particles  of  soil  obtained 
from  the  streets  or  from  cultivated  land,  when  inoculated  on  white  mice, 


246  GENERAL  DISEASES. 

were  frequently  capable  of  setting  up  a  train  of  symptoms  which  strikingly 
resembled  what  one  observed  in  experimental  tetanus.  He  ascribed  the 
disease  to  the  presence  of  small  slender  bacilli,  with  round  spores  at  one 
of  their  extremities.  It  was  not  till  1889  that  Kitasato  succeeded  in 
separating  this  organism  in  a  pure  form,  and  proved  definitely  the  relation 
of  this  bacillus  to  the  disease.  He  found  that  it  was  an  anaerobic  bacillus, 
which  would  not  grow  in  the  presence  of  oxygen,  and  which  flourished 
best  in  a  hydrogen  atmosphere  at  the  temperature  of  the  blood  (37°  C). 
This  organism  is  readily  stained  by  most  of  the  ordinary  dyes,  and  Gram's 
method  is  very  useful  for  demonstrating  its  presence.  The  bacillus  in  its 
vegetative  state  is  actively  motile,  and  may  form  long  threads  which 
undergo  segmentation  and  become  motionless  when  the  process  of 
sporulation  commences.  At  one  end  of  each  of  the  rods  a  highly  refractile 
point  is  observed,  which  becomes  larger  and  larger  until  it  causes  dis- 
tension of  the  bacillus,  in  which  it  is  developed,  and  thus  is  formed  what 
is  known  as  the  "  drum-stick  "  bacillus.  These  spores  require  a  tempera- 
ture of  100°  C,  15  hours  in  5  per  cent,  carbolic,  or  3  hours  in  1  per  cent, 
corrosive  sublimate  solution,  for  their  destruction. 

It  has  been  found  that  the  tetanus  bacillus  is  localised  entirely  to  the 
region  of  inoculation,  and  never  invades  the  blood  or  other  organs  of  the 
body.  This  striking  phenomenon  can  be  explained  only  by  the 
circumstance  that  the  bacillus  at  first  multiplies  at  the  point  of 
inoculation,  and  there  generates  an  extremely  virulent  poison,  which  is 
absorbed,  and  then  affects  the  nervous  system.  Kitasato  has  been  able  to 
separate  this  poison  from  cultures  of  the  bacillus,  and  by  its  means  to  set 
up  the  train  of  symptoms  characteristic  of  the  disease.  Sidney  Martin 
has  shown  that  the  bacillus  produces  in  cultures  a  ferment  toxine,  an 
albumose,  and  an  acid  body,  all  of  which  probably  play  a  part  in  the 
production  of  the  symptoms.  He  has  also  been  able  to  separate  these 
toxines  from  the  organs  of  tetanus  cases,  which  supplies  a  most  important 
corroboration  of  the  relation  of  this  bacillus  to  the  disease. 

Behring  and  Kitasato  in  1890  succeeded  in  rendering  animals  immune 
to  this  disease,  and  found  that  their  serum  contained  an  antitoxine  capable 
of  completely  neutralising  the  tetanus  toxine,  and  which  was  in  all  other 
respects  analogous  to  the  diphtheria  antitoxine. 

Etiology. — The  origin  of  the  disease  is  due  to  the  entrance  of  the 
tetanus  bacillus  and  the  production  at  the  seat  of  inoculation  of  a  specific 
toxine,  which  affects  specially  the  motor  centres  of  the  nervous  system. 
Careful  examination  has  failed  to  discover  the  presence  of  the  organism  in 
the  blood  or  internal  organs,  and  everything  goes  to  show  that  the  process, 
as  in  the  case  of  diphtheria,  is  a  purely  local  one,  while  the  systemic 
effects  are  due  to  the  absorption  of  the  poison.  The  organism  usually 
finds  its  entrance  through  an  obvious  wound,  hut  this  may  be  of  the 
most  trivial  description,  such  as  the  bite  of  an  insect,  a  mere  scratch,  or 
the  puncture  caused  by  subcutaneous  injection.  The  organism,  as  one 
would  expect,  has  a  better  chance  of  finding  an  entrance  in  cases  of  severe 
or  lacerated  wounds,  burns,  or  where  foreign  bodies  are  lodged  in  the 
tissues.  The  occurrence  of  the  disease  is  most  frequently  to  be  feared  when 
the  parts  have  been  exposed  to  contact  with  earth  and  dirt,  but  this,  of  course, 
presupposes  the  presence  of  the  specific  organism  in  these.  The  bacillus, 
as  has  already  been  mentioned,  is  found  most  frequently  in  cultivated  soil, 
and  it  has  been  stated  occurs  specially  in  the  manure  from  horses  and  in 
the  sweepings  from  stables.     In  this  relation  some  experiments  by  Koux. 


TETANUS.  247 

and  Vaillard  may  be  noticed,  which  would  seem  to  indicate  that  the 
tetanus  organism  itself  is  unable  to  set  up  the  disease.  They  found  that 
the  spores  of  the  tetanus  bacillus,  when  they  had  been  freed  by  washing 
from  the  toxine,  were  unable  to  affect  even  very  susceptible  animals.  The 
addition  of  a  small  quantity  of  the  toxine,  or  the  addition  of  the  products 
of  other  microbes,  or  even  the  bruising  of  the  tissues  locally,  sufficed, 
however,  to  allow  the  inoculation  to  set  up  a  fatal  attack  of  tetanus. 
These  experiments  show  the  importance  of  the  local  element  in  the  disease, 
and  the  important  part  which  the  pus  organisms,  which  are  so  frequently 
present,  play  in  the  process.  It  is  indeed  probably  owing  to  the  absence 
of  suppuration  that  we  must  ascribe  the  less  frequent  occurrence  of 
tetanus  which  followed  the  use  of  antiseptics,  since,  as  we  have  already 
stated,  the  ordinary  antiseptics  are  not  sufficiently  powerful  to  destroy  the 
tetanus  bacillus  spores. 

The  disease  has  been  divided  into  two  forms — the  traumatic,  where  the 
process  can  be  traced  to  a  wound,  and  the  idiopathic  or  rheumatic  form, 
which  was  supposed  to  be  due  to  exposure  to  cold.  Since,  however,  we 
have  come  to  recognise  the  infective  nature  of  the  disease,  the  number  of 
cases  occurring,  classified  under  the  latter  heading,  has  tended  to  become 
less  and  less.  The  disease  is  more  common  in  men  than  in  women,  and 
occurs  more  frequently  in  warm  than  in  temperate  regions. 

Morbid  anatomy  and  pathology. — There  is  usually  present 
hypersemia  of  the  cerebral  nervous  system,  often  with  small  haemorrhages, 
which  occur  specially  in  the  motor  centres.  It  has  been  stated  that  the 
bronchi  are  frequently  the  seat  of  catarrhal  changes,  and  it  has  been 
suggested  that  this  may  be  the  point  of  entrance  of  the  tetanus  organism 
in  idiopathic  tetanus  (Babes). 

Symptomatology. — The  disease  is  characterised  by  the  occurrence 
of  tonic  spasms  of  the  voluntary  muscles,  commencing  in  those  of  the  face 
and  neck,  and  gradually  extending  to  all  the  muscles  of  the  body.  The 
most  characteristic  symptom  of  the  disease  occurs  when  the  muscles  of 
mastication  are  affected — the  temporal  and  masseter  muscles  being 
contracted,  and  standing  out  in  bold  relief,  so  that  the  jaws  are  tightly 
clenched,  giving  rise  to  the  popular  name  of  the  disease — "  lockjaw."  The 
scientific  designation  of  this  condition  is  trismus,  and  it  is  most  important 
in  the  diagnosis  of  the  disease.  When  the  muscles  of  expression  are 
affected,  a  peculiar  and  most  typical  appearance  is  presented,  which  is 
described  as  the  risus  sardonicus.  Paroxysms  of  clonic  spasms  supervene 
on  the  tonic  spasms  at  a  later  period  of  the  disease,  and  are  usually  set  up 
by  some  external  irritation  acting  through  any  of  the  senses.  There  is 
frequently  observed  towards  the  end  of  the  case,  fever  and  rise  of  respira- 
tion and  pulse  rate.  Sleeplessness  usually  prevails  during  the  course  of  the 
disease. 

Diagnosis. — The  disease  is  recognised  by  the  nature  of  the  spasms 
and  the  history  of  the  case.  A  bacteriological  examination  of  the  pus  may 
be  made  either  microscopically  for  the  characteristic  organism,  or  by  the 
inoculation  of  a  mouse  at  the  root  of  the  tail,  which  in  cases  of  tetanus 
usually  dies  in  the  course  of  two  or  three  days,  exhibiting  the  characteristic 
symptoms  of  the  disease. 

Prognosis. — In  the  milder  form  of  tetanus,  which  has  been  termed 
chronic,  a  considerable  proportion  of  the  cases  recover,  but  in  the  more 
acute  cases  the  prognosis  is  very  unfavourable. 

The  severity  of  the  disease  appears  to  vary  inversely  with  the  period  of 


248  GENERAL  DISEASES. 

incubation,  the  longer  the  interval  which  has  elapsed  between  the  origin  of 
the  disease  and  the  onset  of  the  symptoms,  the  milder  the  form  of  attack. 
Those  cases  whose  incubation  period  is  twelve  or  fourteen  days,  in  which 
the  temperature  does  not  rise  over  39°  C.  with  little  dyspnoea,  are  mild  in 
their  character,  and  may  usually  be  successfully  treated  by  serum  therapy. 
The  acute  cases  with  an  incubation  period  of  from  five  to  seven  days,  with  a 
temperature  over  40°  C,  with  rapid  appearance  of  the  spasms,  are  much  less 
hopeful  cases  for  treatment. 

Treatment. — The  treatment  up  to  quite  recently  has  been  simply  that 
of  meeting  the  symptoms,  and  attempting  to  keep  the  patient  alive  during 
the  course  of  the  attack.  Nourishment  must  be  given  regularly,  and  to 
procure  rest  and  overcome  the  sleeplessness,  chloral  hydrate  has  been  given 
in  large  doses.  The  subcutaneous  injections  locally  of  1  per  cent,  carbolic 
acid  were  at  one  time  strongly  recommended.  This  treatment  was  based 
upon  the  local  action  of  the  antiseptic,  and  upon  the  fact  observed  by 
Kitasato  that  this  substance  destroyed  the  tetanus  toxine.  More  recently 
the  antitoxine  discovered  by  Behring  and  Kitasato  has  been  used  in  this 
disease,  but  it  must  be  acknowledged,  as  pointed  out  by  Kanthack,  that  the 
successful  cases  which  have  been  recorded  appear  to  be  those  more  chronic 
forms  of  the  affection,  a  considerable  proportion  of  which  recovered  under 
former  methods  of  treatment.  The  want  of  success  with  this  antitoxine,  as 
compared  with  that  observed  in  the  treatment  of  diphtheria,  is  undoubtedly 
due  to  the  remedy  being  administered  at  a  much  later  stage  of  the  disease. 
At  the  period  when  trismus  appears,  when  the  disease  is  usually  recognised, 
the  disease  is  not  in  its  initial  stages,  but  has  already  advanced,  the  toxines 
having  already  combined  with  the  nerve  cells,  probably  of  the  motor  centres. 
The  administration  of  the  antitoxine  acts  by  uniting  with  the  toxine,  and 
thus  prevents  its  combining  with  the  nerve  cells,  but  when  injected  at  this 
late  stage  it  can  practically  only  prevent  the  action  of  any  further  toxine 
which  may  be  absorbed.  If  we  could  only  diagnose  the  disease  at  an 
earlier  stage,  experiments  on  animals  show  that  the  results  obtained  would 
be  as  satisfactory  as  those  obtained  in  the  case  of  diphtheria. 

A  modification  of  the  antitoxine  treatment  has  more  recently  been 
introduced  by  Eoux  and  Borrel.  They  found  that  by  intracerebral 
injection  of  the  antitoxine,  a  much  larger  proportion  of  guinea-pigs,  which 
had  received  a  lethal  dose  of  toxine,  could  be  saved  than  if  the  serum  had 
been  introduced  subcutaneously.  Thus  they  were  able  to  save  thirty-five 
out  of  forty-five  guinea-pigs  when  they  received  the  injection  into  the 
brain,  while  out  of  seventeen  which  received  the  antitoxine  subcutaneously 
only  two  recovered.  This  mode  of  treatment  is  still  upon  its  trial,  but  the 
laboratory  experiments  would  certainly  lead  us  to  expect  that  a  certain 
number  of  the  subacute  cases  which  would  otherwise  die  may  possibly  be 
saved  by  this  method. 

The  use  of  the  tetanus  antitoxine  for  prophylactic  purposes  has  been 
found  very  efficacious  for  horses  in  certain  parts  of  France,  where  these 
animals  frequently  succumb  to  this  disease  after  undergoing  the  operation 
of  castration.  This  suggests  the  advisability  of  administering  prophylactic 
injections  of  the  antitoxine  where  one  case  out  of  a  number  exposed  to  the 
same  conditions  has  developed  symptoms  of  tetanus. 

G.  CAETWKIGHT  WOOD. 


EPIDEMIC  CEREBROSPINAL  MENINGITIS.  249 


EPIDEMIC  CEEEBKO-SPLNTAL  MENINGITIS. 

This  is  an  acute  febrile  disease  occurring  epidemically,  characterised  by 
marked  nervous  symptoms  due  to  inflammation  of  the  membranes  of  the 
cerebro-spinal  system. 

History. — Epidemics  of  this  disease  were  first  recognised  at  the 
beginning  of  this  century,  and  since  that  period  they  have  been  observed 
from  time  to  time  in  different  parts  of  Europe  and  in  the  United  States. 
In  1846  it  appeared  in  many  workhouses  in  Ireland,  but  England  and 
Scotland  have  remained  remarkably  free  from  the  disease.  Early  in  1886, 
Netter  and  Frankel  published  almost  simultaneously  descriptions  of  an 
organism  associated  with  this  disease.  They  found  in  primary  cases  of 
meningitis  an  encapsulated  coccus,  occurring  either  as  diplococci  or  as 
chains,  which  could  be  cultivated  on  agar-agar  at  the  temperature  of  the 
blood,  and  which  presented  all  the  characters  of  the  pneumococcus  of 
ErankeL  In  addition,  this  organism  was  able  to  set  up  in  white  mice  and 
rabbits  a  fatal  disease  precisely  similar  to  that  observed  on  the  injection 
of  the  pneumococcus.  The  introduction  of  this  organism  into  the  brain  of 
certain  animals  gave  rise  to  an  inflammation  similar  to  that  observed  in 
this  disease  in  the  human  species.  It  must  be  admitted,  however,  that 
the  material  obtained  from  different  cases  varied  greatly  in  its  virulence. 
This  form  of  meningitis  occurs  not  only  as  a  primary  affection,  but  has 
also  been  found  on  a  number  of  occasions  as  secondary  to  pneumonia. 
The  pneumococcus  has  now  been  separated  from  quite  a  number  of  un- 
doubted cases  of  the  epidemic  forms  of  the  disease  by  a  series  of  reliable 
observers,  but  the  etiological  relation  of  this  organism  is  still  unsettled,  as 
another  very  characteristic  organism  has  also  been  observed  in  some  of 
these  cases.  "Weichselbaum  found  the  pneumococcus  in  two  out  of  eight 
cases,  but  in  the  six  others  he  observed  small  hemispheres  with  flattened 
opposed  ends  greatly  resembling  gonococci,  not  only  in  their  appearance, 
but  also  in  the  fact  that  they  were  usually  found  within  the  body  of  the 
cells.  To  this  organism  he  gave  the  name  of  Dijjlococcus  intracellular  is 
meningitidis;  this  organism  is  also  found,  according  to  Netter,  frequently 
in  association  with  the  diplococcus  in  these  cases,  but  it  sometimes  occurs 
alone. 

Etiology. — It  is  most  generally  believed  not  to  be  directly  contagious, 
although  it  almost  invariably  occurs  in  the  form  of  an  epidemic.  The 
discovery  of  a  microbe  apparently  associated  with  this  disease  has,  how- 
ever, led  many  to  support  its  contagious  nature.  ISTetter  explains  the  fact 
that,  as  a  rule,  those  in  contact  with  a  case  are  not  affected  with  the 
disease,  by  pointing  out  that  the  infective  material  is  usually  shut  up  in 
the  cranial  cavity,  and  that  only  those  cases  where  the  organism  occurs  in 
the  nasal  discharge  and  in  the  pus  from  the  ears  and  eyes  are  probably 
infective.  The  advocates  of  the  contagious  point  of  view  direct  attention 
to  the  fact  that  those  attending  on  the  sick  have  in  a  number  of  cases 
contracted  the  disease,  and  also  that  not  unfrequently  a  number  of  cases 
occur  in  the  same  house ;  in  addition,  they  assert  that  the  origin  of  an 
epidemic  may  sometimes  be  traced  to  an  imported  case  of  the  disease. 

Children  are  most  frequently  affected,  although  others  up  to  the  age 
of  sixty  may  contract  the  disease.  The  disease  is  more  widely  prevalent 
in  temperate  zones,  and  is  said  to  occur  more  frequently  in  cold  than  in 
hot  weather. 


250  GENERAL  DISEASES. 

Morbid  anatomy  and  pathology. — The  characteristic  feature  of 
the  disease  is  an  inflammation  of  the  membranes  of  the  brain  and  spinal 
cord,  especially  of  the  arachnoid,  which  is  usually  covered  with  a 
yellowish  deposit  of  lymph  over  this  membrane  at  the  base  of  the  brain 
and  the  anterior  part  of  the  medulla  oblongata.  The  ventricles  and 
arachnoid  spaces  are  filled  with  serous  effusion,  while  the  sinuses  are 
filled  with  dark-coloured  blood.  The  membranes  of  the  spinal  cord  are 
also  affected  in  a  similar  manner.  Congestion  and  oedema  of  the  lungs 
is  sometimes  present  along  with  congestion  of  the  spleen  and  liver.  Eigor 
mortis  is  said  to  be  of  long  duration. 

Symptomatology. — One  of  the  most  characteristic  features  of  the 
disease  is  the  abruptness  of  the  seizure  and  the  rapidity  with  which  the 
symptoms  develop.  The  patient  suffers  from  extreme  nervous  shock, 
cephalalgia  and  intense  pain  referred  to  the  back  of  the  head  and  neck, 
which  ultimately  invades  the  extremities,  accompanied  by  spasmodic  con- 
traction of  the  muscles.  The  pain  does  not  appear  to  be  increased  so  much 
by  direct  pressure,  every  effort  of  the  patient  being  directed  to  avert 
movement  and  preserve  a  state  of  immobility.  This  is  indicated  by  the 
peculiar  and  characteristic  attitude  which  is  usually  observed  in  this 
disease.  The  head  is  thrown  backwards  on.  the  nucha,  so  as  to  lie  almost  at 
a  right  angle  to  the  spine,  which  is  extended  and  sometimes  even  arched 
as  in  tetanus,  a  condition  which  it  somewhat  resembles  owing  to  the 
rigidity  of  the  muscles  which  tend  to  maintain  the  patient  in  this  position. 

Eruptions  appear  on  the  skin  at  an  early  stage  of  the  disease,  on  the 
second  or  fourth  day,  which  vary  greatly  in  their  character  in  different 
epidemics.  These  may  consist  of  raised  lenticular  rose-coloured  spots,  or 
extensive  purpuric  patches,  usually  on  the  trunk  or  extremities,  while  a 
regular  herpetic  eruption  frequently  occurs  on  the  face. 

If  the  patient  recovers  from  the  condition  of  collapse,  a  state  of  reaction 
usually  sets  in,  when  the  temperature  may  rise  from  100°  F.  to  103°  F., 
and  frequently  a  general  amelioration  of  the  symptoms  is  observed,  which 
raises  hopes  which  are,  however,  but  seldom  realised.  Delirium  is  rarely 
absent  during  the  course  of  the  disease,  and  frequently  the  patient  lies  in  a 
state  of  coma. 

As  a  result  of  this  disease  we  may  have  hemiplegia  or  paraplegia,  due 
probably  in  the  one  case  to  a  cortical  lesion,  and  in  the  other  case  to  a 
spinal  lesion.  Deafness  or  sometimes  a  low  form  of  inflammation  of  the 
eyes  may  occur. 

Diagnosis  and  Prognosis. — The  history  of  the  case  and  the 
symptoms  usually  leave  no  doubt  as  to  the  nature  of  the  disease.  It  is 
quite  probable  that  in  the  later  stages  the  serum  of  the  patient  might 
be  used  for  purposes  of  diagnosis.  The  mortality  in  this  disease  is  very 
high,  probably  on  an  average  60  per  cent,  succumbing,  but  apparently 
the  death-rate  varies  considerably  in  different  epidemics.  The  prognosis 
must  always  be  unfavourable. 

Treatment. — In  view  of  the  infective  nature  of  this  disease,  isolation 
and  disinfection  ought  to  be  carried  out.  To  relieve  the  headache  and 
diminish  excitement,  the  patient  should  be  kept  in  a  cool,  dark,  well- 
ventilated  room ;  the  head  should  be  shaved  and  ice  applied  to  it,  and  also 
to  the  neck  and  back  if  necessary.  Opiates  may  sometimes  be  used  in  the 
early  stage  of  the  disease,  but  probably  do  not  affect  its  course. 

G.  CAETWEIGHT  WOOD. 


B  UB  ONIC  PL  A  GUE.  251 


BUBONIC  PLAGUE. 


An  epidemic  communicable  disease  caused  by  the  presence  of  a  specific 
bacterium — Bacillus  pestis — in  the  blood  and  tissues,  and  characterised  by 
fever  of  an  adynamic  type,  polyadenitis,  buboes,  and  a  very  high  mortality. 

History  and  geographical  distribution. — Introduced  from  the 
East  some  centuries  before  the  Christian  era,  plague  was  at  one  time  well 
known  in  Europe,  where,  during  the  Middle  Ages,  the  constantly  recurring 
epidemics  caused  an  enormous  mortality.  With  the  advance  of  civilisation, 
and  consequent  improved  hygiene,  it  gradually  died  out.  With  one  exception 
(Portugal),  it  has  not  been  seen  in  Europe  since  1841,  when  it  visited 
Constantinople  for  the  last  time.  A  small  epidemic  occurred  in  the  Eussian 
province  of  Astrakan  in  1878  and  1879,  but  speedily  died  out.  It  finally 
disappeared  from  England  in  1679.  The  Great  Plague  of  London  (1664- 
65)  destroyed  70,000  of  the  460,000  inhabitants  of  the  city  of  that  day. 
Until  1899  it  had  never  been  seen  in  America,  nor  in  the  southern  hemi- 
sphere. Until  a  recent  date,  it  was  confined,  so  far  as  known,  to  Arabia, 
Mesopotamia,  Persia,  India,  China,  and  Uganda. 

Etiology. — The  conditions  under  which  plague  becomes  endemic  are 
fairly  well  known ;  they  are  closely  akin  to  those  favouring  epidemic  out- 
bursts of  typhus  exanthematicus,  that  is  to  say,  personal  and  domestic  filth 
and  overcrowding.  Plague  never  becomes  epidemic  in  the  presence  of 
municipal  and  domestic  cleanliness. 

Predisposition. — Sex  and  occupation  may  have  some  influence  as  affect- 
ing liability  to  infection,  but  they  have  no  very  special  bearing  on 
susceptibility.  Possibly  old  age  has  a  certain  protective  influence. 
Previous  attacks  insure  immunity  for  a  short  time  only ;  they  seem, 
however,  to  progressively  diminish  the  gravity  of  subsequent  infections. 

Soil  and  altitude  have  no  influence  on  the  character  or  diffusion  of  the 
disease. 

Temperature. — High  atmospheric  temperatures,  especially  if  accom- 
panied by  drought,  and  very  low  atmospheric  temperatures,  tend,  for  the 
time  being,  to  suppress  epidemics. 

Bacteriology. — The  cause  of  the  disease  has  been  proved  to  be  a 
minute  bacillus,  closely  resembling  in  morphological  characters  the  bacillus 
of  chicken  cholera  and  those  of  certain  other  septicaemias.  It  was 
discovered  by  Kitasato  and  Yersin  in  the  Hong  Xong  epidemic  of  1894. 
It  occurs  principally  in  the  characteristic  buboes,  in  the  different  viscera, 
and,  more  scantily,  in  the  blood.  It  is  also  present  in  the  alimentary 
canal,  urine,  and  sputum.  The  bacillus  is  easily  demonstrated  by  smearing 
the  pulp  of  one  of  the  buboes  on  a  slide,  fixing  with  alcohol  or  heat, 
and  staining  with  an  aniline  dye.  The  ends  of  the  bacillus  are  rounded 
off,  and  take  the  stain  more  deeply  and  readily  than  the  intermediate 
portion,  giving  the  bacterium  a  dumb-bell  appearance.  It  can  be  culti- 
vated on  blood  serum,  on  agar,  and  in  bouillon.  It  does  not  liquefy 
gelatin.  The  disease  can  readily  be  conveyed  to  many  of  the  lower 
animals  by  inoculation,  either  from  the  glands  and  discharges  of  a  patient, 
or  from  cultures.  Eats  and  mice  are  particularly  susceptible,  but  guinea- 
pigs,  rabbits,  dogs  (?),  and  many  other  animals  readily  take  the  disease  both 
by  inoculation  and  contagion,  and  also  by  the  introduction  into  the 
stomach  of  cultures  or  of  food  containing  the  germ. 

Infectivity. — Plague  is  not  a  very  infectious  disease;  there  is  little 


252  GENERAL  DISEASES. 

risk,  therefore,  to  medical  attendants  and  nurses  in  a  clean,  well-ventilated 
and  roomy  hospital.  In  dark,  overcrowded,  dirty  native  houses,  how- 
ever, when  the  disease  has  once  been  introduced,  it  rapidly  spreads. 
The  exact  conditions  in  which  ordinary  circumstances  determine  diffusion 
are  not  known  with  precision;  but  it  would  seem  probable  that  the 
infection  is  communicable  to  walls,  floors,  furniture,  and  clothing,  and 
that  it  can  be  acquired  from  these,  as  well  as  more  directly  from  close 
proximity  to  patients  actually  suffering  with  the  disease.  A  remark- 
able and  significant  circumstance  in  connection  with  plague  epidemics 
in  man  is,  that  before  the  disease  appears  among  the  people  the  rats 
are  attacked;  they  come  out  of  their  holes  and  die  in  hundreds — in 
fact,  for  the  time  being,  they  become  exterminated  in  the  district.  The 
affected  rats  contain  the  B.  pestis  in  abundance,  and  their  carcases 
exhibit  the  characteristic  polyadenitis  and  other  pathological  features  of 
plague.  It  is  probable,  therefore,  that  the  rat  is  an  important  agent  in 
diffusing  the  disease. 

Epidemic  diffusion. — In  following  the  lines  of  human  intercourse 
the  disease  somewhat  resembles  that  of  cholera ;  but,  as  compared  to  that 
disease,  on  the  whole,  the  diffusion  of  plague  is  much  slower,  its  incidence 
even  more  capricious,  and,  when  established,  its  hold  distinctly  more 
tenacious.  It  tends  to  hang  about  a  district  or  town  for  two  or  three 
years,  picking  out  from  time  to  time  particular  houses — "  plague  houses  " 
— or  areas  which  it  decimates,  and  subsequently  passing  on  to  others 
previously  and,  apparently,  capriciously  spared. 

Morbid  anatomy. — Post-mortem  rises  of  temperature,  and  muscular 
contractions  like  those  occurring  after  death  from  cholera,  are  some- 
times observed.  The  brain  and  meninges  are  congested ;  occasionally 
blood  is  found  extravasated  into  the  substance  of  the  organ.  Ecchymoses 
occur  in  all  serous  membranes.  The  lungs  may  present  evidences  of 
bronchitis,  of  hypostatic  pneumonia,  more  rarely  of  croupous  pneumonia ; 
occasionally  heemorrhagic  infarcts  and  even  abscesses  are  found.  The 
right  heart  and  veins  are  distended  with  feebly  coagulated  or  with  fluid 
blood.  The  liver  and  spleen  are  enlarged.  The  intestinal  mucosa  is 
congested,  presenting  here  and  there  punctate  haemorrhages  and,  occasion- 
ally, particularly  towards  the  lower  end  of  the  ileum,  hsernorrhagic  erosions. 
The  kidneys  and  perinephritic  tissues  are  congested.  The  mucous 
membrane  of  the  ureters  and  bladder  may  be  dotted  with  small  ecchymoses. 
The  lymphatic  system  is  invariably  affected,  the  glands  and,  occasionally, 
the  lymphatic  trunks,  being  inflamed  and  swollen.  The  inflammatory 
effusion  around  the  buboes  is  often  abundant ;  it  is  sero-sanguinolent  in 
character.  The  lymphatic  glands  contain  the  bacillus,  sometimes  mixed 
with  the  bacteria  of  suppuration,  in  great  profusion.  If  death  have  occurred 
early  in  the  disease,  the  signs  of  adenitis  may  not  be  so  pronounced. 

Symptoms.  — After  an  incubation  period  of  from  two  to  eight  days, 
with  or  without  a  prodromal  stage  characterised  by  malaise,  feverishness, 
and  perhaps  pains  in  the  groins,  the  disease  sets  in  with  extreme  lassitude, 
severe  headache,  drowsiness,  vertigo,  perhaps  vomiting  and  fever.  Severe 
rigor  is  not  a  usual  symptom.  The  face  acquires  a  peculiar  expression ;  it 
becomes  haggard ;  the  eyes  are  sunken  and  staring,  the  countenance  some- 
times expressing  fear,  sometimes  indifference  or  bewilderment,  sometimes 
hilarity.  The  patient,  if  walking  be  attempted,  staggers  as  if  drunk,  moving 
about  in  a  dazed  condition.  Temperature  rapidly  rising  to  103°  or  104°,  or 
even  higher,  the  face  becomes  bloated,  the  eyes  red  and.  ferrety  the  hear- 


BUBONIC  PLAGUE.  253 

ing  dulled ;  the  swollen  and  furred  tongue  quickly  dries,  sordes  accumulate 
about  the  mouth,  thirst  becomes  intense,  prostration  complete.  Delirium, 
or  typhoid  stupor,  and  the  various  nervous  phenomena  of  the  typhoid  state, 
rapidly  ensue.  Vomiting,  diarrhoea,  or  constipation  may  any  of  them  be 
present.  The  spleen  and  liver  are  swollen.  The  urine  is  scanty.  Albuminuria, 
though  sometimes,  is  not  always  a  prominent  feature;  like  many  of  the 
clinical  symptoms,  this  is  different  in  different  epidemics.  The  pulse,  at 
first  full  and  bounding,  rapidly  becomes  small,  dicrotic,  and  fluttering.  At 
this  stage  the  patient  may  rapidly  sink  and  die  from  asthenia  or  from 
sudden  syncope.  Should  the  patient  survive,  in  about  two-thirds  of  the  cases, 
some  time  between  the  second  and  fifth  day — in  a  small  proportion  of  cases 
it  may  be  as  late  as  the  eighth  or  ninth  day — buboes  develop ;  they  appear 
usually  on  the  groins  (70  per  cent.),  less  often  in  the  axilla  (20  per  cent.), 
still  more  rarely,  but  especially  in  children,  at  the  angle  of  the  jaw  (10  per 
cent.).  Occasionally  they  are  present  from  the  outset.  These  buboes  are 
generally  single ;  both  sides,  however,  may  be  affected,  and  very  often  there 
is  evidence,  in  the  tenderness  elicited  by  pressure,  that  the  more  superficial 
bubo  is  associated  with  a  similar  adenitis  of  the  deeper  abdominal  glands. 
The  buboes  vary  in  size  from  a  hazel-nut  to  a  goose's  egg,  or  even  much 
larger,  and  are  often  very  painful.  The  surrounding  connective  tissue  and 
superjacent  skin  participate  in  the  inflammation,  and  become  red,  swollen, 
and  infiltrated.  Boils,  carbuncles,  and  purpuric  extravasations  are  occasional 
features,  being  more  common  in  some  epidemics  than  in  others.  In  favour- 
able cases,  on  the  appearance  of  the  bubo,  profuse  perspiration  sets  in,  and 
is  accompanied  by  a  rapid  defervescence  of  fever  and  clearing  away  of  the 
other  symptoms.  The  bubo,  however,  continues  to  enlarge  and  finally 
softens  and  bursts,  discharging  pus  and  evil-smelling  sloughs.  On  the 
other  hand,  suppuration  may  be  delayed  for  weeks ;  or  it  may  not  occur  at 
all,  the  bubo  slowly  resolving.  Convalescence,  when  it  does  set  in,  com- 
mences usually  between  the  sixth  and  tenth  days,  although  subsequently 
there  may  be  much  secondary  trouble  from  sloughing  of  buboes,  from  boils, 
or  from  pyaemic  conditions. 

Abortion  invariably  occurs  in  pregnant  females,  the  foetus  presenting 
evidences  of  the  disease.  A  peculiar  type  of  pneumonia,  haemoptysis,  and 
other  forms  of  haemorrhage,  are  sometimes  a  feature  of  specially  malignant 
epidemics.  Death  in  plague  usually  takes  place  from  the  third  to 
the  fifth  day;  but  in  that  form  which  has  acquired  the  name  "pestis 
siderans,"  it  may  occur  within  the  first  twenty-four  hours — in  twelve 
hours  even. 

Pestis  ambulans. — During  epidemic  plague,  as  with  other  diseases  of 
the  same  class,  milder  cases,  in  which  the  patient  is  able  to  be  about, 
occasionally  occur. 

Pestis  minor. — Epidemics  of  a  disease  associated  with  fever  and  buboes, 
in  every  respect  resembling  true  plague  except  in  the  absence  of  a  high 
mortality,  have  been  recorded  from  time  to  time  as  having  occurred  inde- 
pendently of,  or  as  having  preceded  or  followed,  true  plague.  Their  exact 
etiological  relationship  to  malignant  plague  has  not  been  definitely  settled ; 
there  is  a  feeling  among  epidemiologists  that  in  some  way  the  virus  of  these 
mild  cases  may  become  intensified,  and  that  in  this  way  pestis  minor  may 
culminate  in  the  more  serious  disease 

Mortality. — The  mortality  in  plague  varies  from  50  to  95  per  cent. 
It  is  usually  greatest  at  the  beginning  and  height  of  an  epidemic.  Judging 
from  recent  experience  in  Hong  Kong,  it  is  less  in  Europeans  than  in 


254  GENERAL  DISEASES. 

Asiatics ;  doubtless  this  is  owing  to  the  superior  stamina  of  the  former, 
and  to  the  better  attention  and  treatment  which  they  receive. 

Prophylaxis. — Municipal,  domestic,  and  personal  cleanliness  is  the 
best  preventive  of  plague.  Theoretically,  quarantine  ought  to  be  efficient 
against  its  introduction;  but,  depending  as  quarantine  does  on  the  good 
faith  of  so  many,  and,  in  the  case  of  this  disease,  on  the  exclusion  of  affected 
animals  as  well  as  affected  men,  in  practice  it  must  prove  very  fallible 
indeed. 

On  plague  appearing  in  a  community,  hospital  accommodation  on  a 
suitable  scale  should  be  at  once  provided,  and  daily  house  inspection,  both 
for  the  ensuring  of  cleanliness  and  for  the  discovery  of  the  sick,  instituted 
and  conscientiously  carried  out.  The  sick  as  soon  as  discovered  should  be 
removed  to  hospital,  and  the  house  from  which  they  came  disinfected, 
cleansed,  and  for  a  time  shut  up.  Any  house  of  little  value,  and  provided 
it  be  otherwise  practicable,  should  be  destroyed  by  fire. 

All  rats  should  be  killed  by  trap  or  poison,  and  their  bodies  burned. 
This  measure,  which,  judging  from  the  well-established  fact  of  the  ex- 
treme liability  of  these  rodents  to  plague,  and  from  their  habits,  is  a 
measure  of  the  first  importance,  has  hitherto  been  systematically  ignored 
in  attempts  at  plague  eradication.  My  impression  is  that  a  plague 
epidemic  will  continue  in  a  place  so  long  as  any  rats  survive,  and  that 
when  all  rats  are  dead  it  will  cease  to  spread  and  die  out  spontaneously. 
Manifestly,  so  simple  a  measure  as  the  extermination  of  the  rats  is  one  of 
the  first  things  to  be  attempted  on  the  appearance  of  plague  in  a  com- 
munity, or  better,  in  anticipation  of  the  advent  of  the  disease. 

Plague  fomites — including  clothing  and  dejecta — should  be  disinfected 
by  heat  or  destroyed  by  fire. 

No  one  should  be  allowed  to  enter  a  plague  house  or  hospital  unless  on 
important  business.  The  attendants  on  plague  patients  should  be  careful 
to  avoid  hanging  over  their  patients  unnecessarily ;  they  should  take  their 
food  in  a  separate  room ;  they  should  use  disinfectants  frequently  and 
freely ;  and  they  should  be  specially  careful  never  to  handle  patients  or 
their  fomites  if  they  have  wounds  or  scratches  on  their  hands  unprotected 
by  an  efficient  dressing.  With  these  precautions,  attendants  on  plague 
cases  are  not  likely  to  catch  the  disease. 

Treatment. — Careful  nursing,  feeding,  and  stimulation  are  requisite 
in  every  case  of  plague.  If  there  be  constipation  at  the  outset,  one  full  dose 
of  calomel  is  said  to  be  serviceable  in  checking  vomiting.  For  restlessness, 
delirium,  and  sleeplessness,  hypodermic  injections  of  morphine,  early  in  the 
disease,  are  invaluable  (Lowson) ;  they  must  be  given,  however,  with  circum- 
spection. Severe  pain  in  the  buboes  is  also  best  relieved  by  small  hypo- 
dermics of  morphine.  Alcohol,  strychnine,  ether,  or  ammonia  are  of  use  and 
necessary  when  the  heart  is  flagging.  Diarrhoea,  if  urgent,  is  best  treated 
by  frequent  10-gr.  doses  of  salol.  High  fever  must  not  be  treated  by 
antipyrine  and  similar  depressing  antipyretics ;  they  are  dangerous  in  the 
extreme.  Sponging  of  the  body,  and  ice  or  cold  applications  to  the  head, 
are  the  safest  as  well  as  the  most  effective  antipyretics.  Buboes  may  be 
treated  at  first  with  applications  of  glycerin  and  belladonna ;  later,  when 
fluctuating,  they  should  be  incised  and  dressed  with  iodoform.  Iced  beer, 
iced  stout,  and  particularly  ice-cream,  are  much  appreciated  by  patients ; 
they  were  of  the  greatest  service  in  the  Hong  Kong  epidemic. 

Recently  Yersin  has  brought  out  a  serum  which  he  maintains  is  an 
effective  immunising   as  well  as   therapeutical   agent  in  plague.      It   is 


CHOLERA.  255 

prepared  by  the  repeated  injection  of  cultures  of  B.  pestis  into  the 
horse.  In  time  the  serum  of  the  inoculated  horse  acquires  antitoxic 
virtues  qud  the  bacillus.  Of  twenty-six  cases  treated  with  his  serum  in 
China,  Yersin  claims  to  have  cured  twenty-four.  The  rabbit,  he  says, 
can  be  rendered  immune  by  this  agent;  moreover,  if  an  unprotected 
rabbit  be  inoculated  with  a  virulent  culture  of  the  bacillus,  and  subse- 
quently, within  a  reasonable  time,  be  injected  with  a  sufficient  dose  of  the 
serum,  the  progress  of  the  disease  is  arrested,  and  the  animal,  otherwise 
sure  to  die,  recovers.  Later  experience  of  Yersin's  serum  in  Bombay  does 
not  bear  out  the  favourable  reports  from  China.  Haffkine  has  also 
introduced  a  prophylactic  serum  vaccine,  prepared  from  dead  cultures 
of  the  bacillus ;  it  has  been  extensively  used  in  India,  and  is  favourably 
reported  on. 

PATEICK  MAXSON 


CHOLEEA. 

A  specific,  communicable  epidemic  disease,  characterised  by  serous 
vomiting  and  purging,  cramps,  algidity,  suppression  of  urine,  a  high 
mortality,  and  the  presence  of  a  special  bacterium  in  the  alvine  dis- 
charges. It  is  endemic  in  certain  parts  of  India,  and  possibly  elsewhere. 
Following  the  lines  of  human  intercourse,  it  extends  from  time  to  time  as 
an  epidemic  to  many  parts  of  the  world. 

History  and  geographical  distribution. — Although  there  is 
evidence  of  the  existence  of  this  disease  in  India  from  remote  antiquity, 
its  special  nature  was  not  recognised  by  European  physicians  until 
the  sixteenth  century.  The  great  epidemic  extension  of  1813,  during 
which  cholera  spread  over  nearly  the  whole  of  Asia,  first  drew  marked 
attention  to  the  subject.  It  was  not,  however,  until  1830,  when  cholera 
visited  Europe  for  the  first  time,  that  it  became  an  object  of  careful 
study.  Since  that  epidemic,  1830-32,  there  have  been  at  least  five  other 
great  European  epidemics — 1848-51,  1851-55,  1865-74,  1884-86,  and 
1892-95.  Great  Britain  was  involved  in  1832,  in  1848,  in  1854-55,  and  in 
1866,  but  not  since.  The  last  two  European  epidemics,  although  during 
them  a  considerable  number  of  cases  were  imported,  did  not  take  root  in 
this  country.  In  1832,  and  since,  cholera  has  many  times  extended  to 
America  and  to  parts  of  Africa. 

A  study  of  the  genesis  of  these  various  epidemics  shows  that  cholera 
enters  Europe  by  one  of  three  routes — (1)  by  the  Caspian  and  Eussia; 
(2)  by  the  Persian  Gulf  through  Syria,  Asia  Minor,  and  Turkey ;  (3)  by  the 
Bed  Sea,  Egypt,  and  the  Mediterranean  ports. 

Etiology.  —  The  home  of  cholera  is  said  to  be  in  Lower  Bengal, 
where  it  is  present  at  all  times  and  at  all  seasons.  Thence,  from,  time  to 
time,  it  spreads  as  an  epidemic  over  India,  occasionally  extending  by  the 
routes  just  mentioned  to  Europe,  Africa,  and  America. 

In  its  extensions  it  follows  the  lines  of  hmnan  intercourse,  travelling 
no  faster  than  man  travels.  It  never  originates  spontaneously  in 
absolutely  isolated  spots,  and  rarely  in  places  comparatively  though  not 
entirely  isolated  from  the  rest  of  the  world.  Thus  it  is  unknown  in 
Australia,  New  Zealand,  the  islands  of  the  South  Pacific,  the  Cape  of  Good 
Hope,  the  West  Coast  of  Africa,  the  Orkney  and  Shetland  Islands,  the 
Faroe  Islands,  etc.     From  these  circumstances  it  is  justifiable  to  infer  that 


25 6  GENERAL  DISEASES. 

cholera  is  not  the  result  of  some  meteorological  influence,  or  in  any  sense  an 
air -borne  disease,  as  was  at  one  time  supposed;  but  that  it  depends  on 
a  specific  germ  which  clings  to  man  and  is  transported  solely  by  him, 
either  in  his  body,  or  in  his  clothes,  or  in  some  of  his  other  belongings. 
At  the  same  time  experience  has  shown  that  it  does  not  pass  directly  from 
man  to  man.  Unlike  smallpox,  measles,  and  similar  diseases,  cholera  is 
not  contracted  through  simple  proximity  to  a  patient.  Evidence  of  the 
most  convincing  character  has  shown  that  it  is  generally,  if  not  always,  a 
water-borne  disease ;  that  its  germs,  contained  in  the  discharges  of  the  sick, 
are  first  introduced  into  water,  and  then,  in  this  medium,  gain  access  to  the 
intestinal  canal  of  man.  This  being  the  case,  we  can  understand  how, 
when  cholera  is  first  introduced  into  a  community,  those  insanitary 
conditions  which  favour  fsecal  contamination  of  the  water  supply  also 
favour  the  spread  of  the  disease.  Knowing  this,  we  have  an  explanation 
of  many  of  the  apparently  capricious  features  of  cholera  epidemics;  of, 
for  example,  its  unequal  diffusion  in  the  endemic  and  epidemic  area,  of  its 
sparing  one  house  and  attacking  the  next,  of  its  sparing  one  side  of  a  street 
and  attacking  the  other  side,  and  so  forth.  The  circumstances  of  the  water 
supply  afford  the  explanation ;  one  well  or  reservoir  supplying  a  certain 
set  of  houses  is  contaminated,  whilst  that  supplying  neighbouring  houses 
or  districts  is  not.  On  the  whole,  low-lying  districts  are  more  subject  to 
cholera  than  high  and  dry  situations,  overcrowded  towns  than  sparsely 
populated  districts,  filthy  cities  than  clean — facts  entirely  compatible  with 
the  water-borne  theory  of  the  disease. 

If  the  proofs  are  fairly  complete  that  the  germs  of  cholera  reside  in 
the  dejecta  of  the  patient,  they  are  equally  complete  that  the  mere  fact 
of  swallowing  these  germ-containing  dejecta  is  not  sufficient  to  convey 
the  disease.  Other  conditions  are  necessary — conditions  which  include, 
apparently,  a  certain  predisposition  in  the  individual,  and  also  certain 
epidemic  conditions.  The  nature  of  these  predisposing  and  epidemic  con- 
ditions is  quite  unknown. 

Koch,  in  1883,  separated  from  the  stools  of  cholera  patients  in  Egypt, 
and  later,  in  1884,  in  India,  a  special  bacterium.  This  bacterium  is  now 
universally  admitted  to  be  present  in  the  stools  in  practically  all  cases 
of  cholera,  and  only  in  cholera.  As  a  diagnostic  indication,  therefore,  its 
presence  or  absence  in  the  stools  of  patients  suffering  from  choleraic 
symptoms  is  of  great  value.  By  many  it  is  regarded  not  merely  as  a 
constant  concomitant,  but  as  the  true  germ  of  cholera.  Its  claims  ,to  be 
regarded  as  such  are  very  strong  indeed ;  nevertheless,  being  based  princi- 
pally on  the  fact  of  concurrence,  these  claims  are  not  absolutely  conclusive. 

On  account  of  its  peculiar  curved  shape,  the  bacterium  is  sometimes 
known  as  the  comma  bacillus ;  sometimes  it  is  called  the  cholera  vibrio ; 
sometimes  the  cholera  spirillum.  It  is  a  very  minute,  actively  moving 
organism,  1*5  to  2  /*  in  length  by  *5  to  *6  u,  in  diameter,  about  half  the 
length  and  twice  the  thickness  of  the  tubercle  bacillus.  At  one  or  both  ends, 
at  a  certain  period  of  its  life,  one  or  two  flagella  are  discoverable  on  subject- 
ing the  cholera  bacterium  to  special  staining  processes.  These  flagella  are 
of  great  length — one  to  five  times  that  of  the  bacterium  itself.  It  is 
probable  that  it  is  to  these  flagella  that  the  cholera  vibrio  owes  its  peculiar, 
active,  spirillum-like  movements.  The  bacillus  can  be  cultivated  in  the 
ordinary  culture  media,  especially  if  these  are  rendered  slightly  alkaline.  It 
grows  best  at  a  temperatures  of  from  30°  C.  to  40°  C,  growth  being 
arrested  below  15°  C.  and  above  42°  C.      Desiccation  is  said  to  kill  it. 


CHOLERA.  257 

It  liquefies  gelatin ;  and  in  this  as  in  various  other  culture  media,  it  forms 
characteristic  colonies.  Although  pathogenic  to  many  of  the  lower 
animals,  a  powerful  argument  against  attributing  an  etiological  relationship 
to  the  comma  bacillus  in  respect  to  cholera,  lies  in  the  fact  that  hitherto 
intentional  experiment  with  these  bacilli  has  never  succeeded  in  producing 
in  the  lower  animals,  or  in  man,  a  disease  having  all  the  clinical  features 
of  the  true  epidemic  disease. 

Koch  and  others  have  succeeded  in  producing  a  disease  in  some 
respects  like  cholera,  by  introducing  cultures  of  the  bacillus  into  the 
intestinal  canal  of  the  guinea-pig,  the  contents  of  which  had  been  rendered 
alkaline  by  carbonate  of  soda,  and  the  peristaltic  movements  of  which  had 
been  paralysed  by  opium.  When  the  animals  were  killed,  the  intestine 
was  found  to  contain  a  large  quantity  of  cholera-like  fluid  and  almost 
a  pure  culture  of  the  bacillus,  and  to  exhibit  pathological  changes  closely 
resembling  those  of  true  cholera.  Unfortunately  for  the  claims  of  the 
comma  bacillus,  other  micro-organisms  have  been  found  to  give  rise  to 
similar  effects.  Buchner  has  suggested  that,  in  addition  to  the  comma 
bacillus,  it  is  necessary  for  the  production  of  true  cholera  to  secure  the 
presence  of  some  other,  and  as  yet  unknown  bacterium.  He  regards  the 
disease  cholera  as  the  result  of  a  mixed  infection. 

Morbid  anatomy  and  pathology. — Kigor  mortis  sets  in  early, 
and  lasts  for  a  considerable  time.  Post-mortem  muscular  contraction 
sometimes  causes  curious  movements  of  the  limbs.  If  death  has  taken 
place  during  the  algid  stage,  the  body  has  a  shrunken,  shrivelled,  livid 
appearance,  and  the  tissues  are  all  abnormally  dry.  Occasionally  some 
of  the  muscles  are  found  ruptured,  doubtless  from  the  violence  of  the 
cramps.  The  right  heart  and  large  veins  are  filled  with  dark,  thick,  and 
feebly  coagulated  blood,  which  tends  to  stick  to  and  stain  the  inner  surface 
of  the  vessels.  Fibrinous  clots  may  be  found  in  the  right  heart  and 
extending  into  the  vessels.  The  lungs  are  dry,  shrunken,  and  amende; 
sometimes  they  are  congested  and  cedematous.  The  liver  is  congested,  the 
gall  bladder  full,  the  spleen  small.  Like  the  other  serous  cavities,  the 
peritoneum  is  dry  and  sticky.  The  outer  surface  of  the  bowel  is  generally 
injected  and  rosy-red  in  colour ;  the  bowel  itself  contains  abundance  of  the 
peculiar  rice  water  material  already  referred  to,  and  sometimes  a  little 
blood.  The  mucous  surface  is  pinkish  from  general  congestion,  with  spots 
or  patches  of  an  irregular  and  deeper  congestion  scattered  about  through- 
out its  entire  extent.  Ecchymoses  are  common  in  the  mucosa  as  well  as 
in  the  serous  membranes.  The  intestinal  changes  are  most  pronounced 
towards  the  lower  end  of  the  ileum,  where  Peyer's  patches  and  the  solitary 
glands  are  seen  to  be  congested  and  swollen.  In  other  instances  the  bowel 
may  be  pale  throughout.  Sometimes  the  mucous  surface  has  a  sodden, 
pulpy  appearance,  and  exhibits  exfoliation  of  epithelium ;  this  is  possibly 
a  post-mortem  change.  Sometimes  a  diphtheritic  exudation  is  met  with 
towards  the  lower  end  of  the  ileum.  The  mesenteric  glands  are  congested. 
The  kidneys  also  are  congested,  the  tubules  filled  with  granular  matter,  and 
the  epithelium  cloudy,  granular,  or  fatty  and  detached.  The  bladder  is 
empty  and  contracted.  If  death  have  taken  place  during  the  stage  of 
reaction,  the  tissues  are  moist ;  the  venous  system  relatively  empty ;  the 
lungs  congested,  cedematous,  and  perhaps  inflamed ;  very  probably  there  is 
also  evidence  of  extensive  enteritis. 

The  symptoms  of  cholera  suggest  a  double  action  in  the  virus  producing 
it.  First,  local  irritation  of  the  intestinal  tract ;  second,  poisoning  through 
vol.  1. — 17 


258  GENERAL  DISEASES. 

the  blood — phenomena  which  resemble  those  of  ptomaine,  mushroom,  and 
similar  forms  of  poisoning.  The  secondary  fever  of  cholera  is  manifestly  a 
reaction  from  the  primary  disease,  complicated  by  inflammatory  lesions  the 
result  of  acute  intestinal  irritation. 

Symptoms. — Cholera  may  supervene  on  what  appeared  to  be  an 
ordinary  diarrhoea,  and  which,  in  view  of  the  subsequent  attack,  is  generally 
regarded  as,  and  is  called,  "  the  premonitory  diarrhoea  " ;  or  it  may  declare 
itself  suddenly  in  the  midst  of  apparent  good  health.  When  the  disease 
has  declared  itself,  the  patient  passes  without  pain  enormous  quantities 
of  watery  material.  Stool  follows  stool  in  rapid  succession.  At  first  the 
discharges  are  fsecal  in  character;  they  soon  lose  their  bilious  colour, 
becoming  like  thin  rice  water  in  which  small  white  flocculi  are  held  in 
suspension.  Vomiting  of  similar  material  generally  supervenes.  When 
the  purging  and  vomiting  have  lasted  a  certain  time — not  necessarily  a 
long  time — cramps  of  an  extremely  painful  description  attack  the  muscles 
of  the  extremities,  abdomen,  and  elsewhere,  often  causing  the  sufferer  to  cry 
out  with  pain.  The  patient  now  rapidly  passes  into  a  state  of  collapse,  the 
surface  of  the  body  becoming  cold  and  clammy — perhaps  bedewed  with 
sweat,  the  cheeks  sunken,  the  features  sharp  and  pinched,  the  eye  sockets 
hollow,  the  fingers  and  toes  shrivelled  like  a  washerwoman's,  the  surface 
livid.  The  urine  is  suppressed;  respiration  becomes  rapid  and  shallow, 
perhaps  sighing ;  the  breath  cold,  and  the  voice  sunk  to  a  hollow  whisper. 
The  pulse  at  the  wrist  rapidly  becomes  weak,  flutters,  and  finally  dis- 
appears. The  patient  is  restless,  tosses  about  complaining  of  intense  thirst 
and  of  a  burning  sensation  in  the  chest.  The  temperature  of  the  surface 
sinks  to  93°  or  94°  F.  whilst  that  of  the  interior  of  the  body,  as  indicated 
by  the  thermometer  in  the  rectum,  may  rise  to  101°,  or  even  to  105°. 
Though  occasionally  he  may  wander  slightly,  the  mind  is  usually  clear. 
This,  the  algid  stage  of  cholera,  may  terminate  in  death,  in  rapid  conval- 
escence, or  in  febrile  reaction. 

Death  from  collapse  may  occur  any  time  from  two  to  thirty  hours  from 
the  commencement  of  the  attack.  Should,  however,  the  vomiting  and 
purging  cease,  the  pulse  may  gradually  return  at  the  wrist,  and  the  surface  of 
the  body  become  warm  and  dry.  More  or  less  febrile  reaction  then  sets  in. 
After  some  hours  .urine  is  again  secreted,  the  slight  febrile  reaction 
subsides,  and  in  a  few  days  the  patient  may  be  perfectly  well.  On  the 
other  hand,  on  the  cessation  of  the  acute  symptoms  of  the  algid  stage, 
febrile  reaction  may  pass  into  a  peculiar  typhoid  condition  which  continues 
from  four  to  five  days,  or,  in  severe  cases,  even  longer.  The  sunken  cheeks 
and  hollow  eyes  are  now  filled  out  and  flushed,  the  tongue  becomes  brown 
and  dry,  and  there  may  be  low  delirium  with  tremor  and  subsultus ;  or 
perhaps  a  peculiar  torpid,  apathetic  condition  may  supervene.  In  this 
state  the  motions  are  greenish  or  like  pea-soup ;  they  may  contain  a  certain 
amount  of  blood,  and  be  very  offensive.  The  reappearance  of  the  urine  in 
such  cases  may  be  delayed  from  two  to  six  days.  On  its  first  appearance  it 
is  scanty,  high  coloured,  cloudy,  albuminous,  and  contains  casts.  Various 
complications,  such  as  pneumonia,  enteritis,  asthenia,  and  uraemic  troubles 
— as  coma  and  convulsions — may  prove  fatal. 

Such,  briefly,  are  the  principal  clinical  features  of  cholera.  They  may 
vary  very  much  in  severity  and  in  the  predominance  of  particular  symptoms. 
Mild  ambulatory  cases  occur ;  on  the  other  hand,  rapidly  fatal  cases  of  but 
three  or  four  hours'  duration  are  by  no  means  rare.  It  is  generally  stated 
that  the  earlier  cases  in  an  epidemic  are  the  most  severe,  and  that  those 


CHOLERA.  259 

occurring  towards  the  end  of  an  epidemic  are  milder.  A  fatal  type  of  the 
disease  is  what  is  known  as  "  cholera  sicca."  In  such,  although  there  is 
very  little  diarrhoea  and  vomiting,  collapse  sets  in  rapidly,  the  patient 
dying  in  a  few  hours  without  active  purging  or  any  attempt  at  reaction. 
In  these  cases,  post-mortem  examination  discovers  abundance  of  the 
characteristic  rice  water  material  in  the  intestine.  Sometimes  cases  die 
suddenly  from  apnoea  caused  by  coagula  in  the  right  heart,  or,  it  is 
conjectured,  by  sudden  spasm  of  the  pulmonary  arteries.  Occasionally, 
after  temporary  improvement,  relapse  may  set  in  and  is  nearly  always  fatal. 
Hyperpyrexia  may  supervene;  it  is  rare,  but  when  it  does  occur  it  is 
almost  invariably  fatal. 

The  sequelae  of  cholera  are  various  —  anaemia,  mental  and  physical 
debility,  insomnia,  irregular  febrile  conditions,  chronic  enterocolitis, 
different  forms  of  pulmonary  inflammation,  ulceration  of  the  cornea, 
gangrene,  and  so  forth.  Pregnant  women  almost  invariably  miscarry,  the 
foetus  showing  evidences  of  cholera. 

Diagnosis. — Cholera  resembles  very  closely  many  other  diseases; 
among  others,  and  especially,  cholera  nostras,  acute  diarrhoea,  mushroom 
poisoning,  ptomaine  poisoning,  some  forms  of  malarial  fever,  the  early 
stages  of  trichinosis.  Diagnosis  may  be  extremely  difficult  in  sporadic 
cases ;  but  during  an  epidemic  of  cholera  acute  purging  of  rice  water  stools 
can  hardly  fail  to  be  the  result  of  the  virus  producing  the  prevailing 
disease.  A  bacteriological  examination  may  be  necessary  to  establish  the 
diagnosis.  The  absence  of  bile  in  the  rice  water  stools,  the  vomiting  of  a 
similar  material,  the  suppression  of  urine,  the  cramps,  the  cold  shrivelled 
skin,  the  hollow  whispering  voice,  and  the  prostration,  taken  together  are 
fairly  diagnostic.  From  algid  types  of  pernicious  malarial  fever,  a  blood 
examination,  in  conjunction  with  the  history  of  the  case  and  the  character  of 
the  prevailing  epidemic,  should  suffice.  It  is  well  to  note  that  in  malarial 
choleraic  diarrhoea  a  certain  amount  of  bile  is  almost  always  present  in 
the  stools.  The  early  stages  of  trichinosis  may  be  inferred  from  the  history 
of  the  case  or  cases,  the  discovery  of  adult  trichinae  in  the  stools,  and  the 
subsequent  history.  Ptomaine  and  mushroom  poisoning  and  cholera 
nostras  may  be  diagnosed  from  a  consideration  of  the  concurrent  circum- 
stances, and  the  absence  of  the  cholera  vibrio  from  the  stools. 

Prognosis. — About  half  of  those  attacked  with  cholera  die ;  in  some 
epidemics,  and  especially  at  the  early  stage,  the  mortality  is  even  greater. 
The  young,  the  old,  the  weak,  die  more  readily  than  the  middle-aged  and 
robust.  Pregnancy,  disease  of  the  kidneys  or  of  the  liver,  and  dissipated 
habits,  aggravate  the  mortality.  As  regards  individual  attacks,  rapid 
progress,  sudden  seizure,  extreme  restlessness,  rapidly  failing  pulse,  intense 
algidity,  hyperpyrexia,  persistent  suppression  of  urine,  jaundice,  lung  and 
other  complications,  relapses  of  purging  and  vomiting,  well-marked  typhoid 
symptoms,  uraemia,  delirium,  are  all  bad  signs.  In  the  algid  stage,  so  long 
as  the  pulse  can  be  felt  at  the  wrist,  and  the  temperature  of  the  body  is 
not  exceedingly  depressed,  the  prognosis  is  more  hopefuL  In  the  stage  of 
reaction,  in  the  absence  of  high  temperature  and  of  typhoid  symptoms  the 
prognosis  is  good.  The  return  of  bile  in  the  stools,  of  the  urinary 
secretion,  of  surface  warmth,  and  of  surface  colour  are  good  signs. 

Treatment. — The  prevention  of  cholera  is  to  be  sought  for  in 
domestic  and  municipal  cleanliness,  in  a  pure  water  supply,  in  isolation 
of  the  sick  and  destruction  of  their  fomites  by  fire  or  disinfectants,  in  a 
rigid  exclusion  of  the  discharges  from  the  water  and  food  supply  of  the 


26o  GENERAL  DISEASES 

community.  Theoretically,  strict  quarantine  should  be  an  efficient  safe- 
guard ;  practically,  it  is  not  so.  On  the  contrary,  owing  to  the  feeling  of 
false  security  it  engenders,  it  leads  to  neglect  of  sanitation.  The  modified 
quarantine,  as  practised  in  Great  Britain,  in  which  free  pratique  is  given  to 
all  ships  except  those  with  cholera  patients  on  board,  together  with  careful 
sanitation,  seems  to  be  the  most  successful  system  for  keeping  the  disease 
at  bay.  During  epidemics  of  cholera,  care  should  be  taken  to  maintain  the 
general  health  at  a  high  standard,  to  avoid  such  things  as  may  lead  to 
derangement  of  the  intestinal  organs — uncooked  fruit  or  vegetables, 
decomposing  food  of  all  sorts,  excess  in  alcohol,  purgative  medicines — 
particularly  salines — exposure,  and  fatigue.  At  these  times  water  and 
milk  ought  to  be  boiled,  and  all  cooking,  eating,  and  drinking  vessels 
washed  in  boiled  water. 

Haffkine  has  recently  introduced  a  system  of  anticholera  vaccina- 
tion with  the  object  of  producing  artificial  immunity.  His  subcutaneous 
injections  of  cultures  of  the  cholera  vibrio  have  been  extensively  used  in 
India;  apparently  they  have  met  with  a  certain  amount  of  success, 
sufficient  at  all  events  to  justify  further  and  more  extended  trial.  On  the 
assumption  that  the  comma  bacillus  is  the  germ  of  cholera,  they  are 
correct  in  principle ;  they  are  thoroughly  effective  in  the  lower  animals 
against  poisoning  by  this  microbe. 

A  vast  number  of  drugs  have  been  tried  from  time  to  time  in  the 
treatment  of  this  disease  ;  it  cannot  be  said  that  much  success  has 
attended  their  use.  Practically,  the  treatment  of  cholera  resolves  itself 
into  careful  nursing  and  the  relief  of  suffering.  Experience  has  shown  that 
it  is  advisable  by  means  of  opium  and  other  astringents  to  check  diar- 
rhoeas during  cholera  epidemics ;  chlorodyne  is  perhaps  the  most  generally 
used  and  most  convenient  form  of  administering  opium.  This,  or,  when 
vomiting  is  present,  the  hypodermic  injection  of  morphine,  together  with 
rest,  is  probably  the  most  valuable  means  of  treatment  at  our  disposal. 
Lead  and  opium  pill,  diarrhoea  mixtures  containing  opium  and  carminat- 
ives, dilute  sulphuric  acid,  etc.,  are  also  often  used. 

It  is  a  mistake  to  attempt  to  feed  or  stimulate  a  patient,  either  during 
the  premonitory  diarrhoea  or  while  active  choleraic  purging  and  vomiting 
are  proceeding.  At  such  times  absorption  is  in  abeyance,  and  food  only 
adds  to  the  derangement  of  the  stomach  and  bowels.  The  intense  thirst 
is  best  relieved  by  small  quantities  of  ice  or  iced  effervescing  drinks;  the 
cramps  by  small  hypodermic  injections  of  morphine  and  by  gentle  rubbing 
of  the  muscles,  with  or  without  a  liniment.  When  vomiting  has  ceased, 
possibly  a  cautious  use  of  iced  champagne  or  of  weak  brandy  and  water 
may  help  to  restore  the  circulation.  The  pidse  can  sometimes  be  brought 
back  by  nitrite  of  amyl  inhalation  ;  or,  better,  by  intravenous  injection  of 
warm  saline  solutions — 60  grs.  of  common  salt,  30  grs.  of  carbonate  of  soda, 
to  the  quart  of  distilled  sterilised  water  at  a  temperature  of  about  98°4  F. 
The  injection  should  be  made  by  gravitation  and  slowly,  at  the  rate  of 
about  a  quart  in  a  quarter  of  an  hour,  the  effect  being  carefully  watched ; 
from  one  to  three  quarts  may  be  required  to  restore  the  pulse.  Some- 
times this  treatment  has  succeeded  in  saving  life ;  usually,  however,  the 
improvement  is  but  temporary,  purging  and  vomiting  rapidly  removing 
the  fluid  injected. 

It  is  of  importance  to  maintain  the  temperature  of  the  surface  of  the 
body.  "With  this  in  view,  the  room  must  be  kept  at  or  over  70°  F. 
Warm  baths,  or  warm  bricks  or  bottles  may  be  placed  about  the  patient. 


DYSENTERY.  261 

who  should  be  covered  with  a  blanket,  but  not  oppressed  by  too  much 
clothing.     The  surface  should  be  kept  dry  by  frequent  wiping. 

During  reaction,  great  care  must  be  taken  in  feeding.  Food  should 
be  given  in  small  quantities — teaspoonfuls  of  milk  every  quarter  of  an 
hour,  or  teaspoonfuls  of  some  meat  jelly.  If  reaction  is  excessive  and 
there  is  much  fever,  sponging  of  the  surface  or  rectal  injection  of  cold 
water  may  be  tried.  Dry  cupping,  hot  fomentation,  and  poultices  over 
the  kidneys,  and  diluents  may  be  had  recourse  to  in  persistent  suppression 
of  urine ;  everything  like  stimulating  diuretics  must  be  avoided.  Con- 
stipation is  best  relieved  by  enemata;  diarrhoea,  by  large  enemata  of 
solution  of  tannin. 

During  convalescence,  tonics,  change  of  air,  and  careful  dieting  are 
indicated. 

PATRICK  MAKSOK 


DYSENTEEY. 

Syn.,  Fr.,  Dysenterie ;  Ger.,  Ruhr. 

The  term  "dysentery"  is  applied  to  a  group  of  symptoms — tormina, 
tenesmus,  and  the  frequent  passage  of  scanty  mucoid  or  muco-sanguinolent 
stools — depending  on  inflammation  of  the  mucous  membrane  of  the  colon. 
It  probably  includes  several  etiologically  distinct  diseases. 

History  and  geographical  distribution. — Dysentery  has  been 
recognised  from  remotest  antiquity.  Galen  attributed  it  to  the  irritating 
effects  of  an  acrid  bile  ;  Sydenham  regarded  it  as  the  local  expression  of 
a  general  disease ;  modern  medicine  inclines  to  look  "upon  it  as  a  purely 
local  disease,  resulting  from  invasion  of  the  mucous  membrane  of  the  colon 
by  one  or  more  species  of  micro-organism. 

Dysentery  is  found  all  over  the  world.  Like  malaria,  its  frequency 
and  severity  tend  on  the  whole  to  increase  as  the  equator  is  approached. 
It  is  unevenly  distributed,  some  districts  being  more  subject  to  it  than 
others.  It  is  endemic  in  many  places,  and,  like  malaria,  is  generally 
most  prevalent  in  low-lying,  damp  localities.  Unlike  malaria,  it  has  no 
exclusive  predilection  for  the  country,  being  nearly  though  not  quite  as 
common  and  often  quite  as  severe  in  towns.  Although  sporadic  cases 
and  occasionally  small  and  limited  epidemics  do  occur  in  temperate 
climates,  in  them  at  the  present  day  it  is  principally  during  war,  in  camps 
and  sieges,  during  times  of  want,  and  in  large  public  institutions — as  jails 
or  lunatic  asylums — the  subjects  of  grave  sanitary  defects,  that  this  disease 
becomes  extensively  epidemic.  Drainage,  cultivation,  improved  water 
supply,  improved  food  and  sanitation  generally,  tend  to  repress  dysentery ; 
they  have  done  much  to  banish  it  from  Britain,  where  at  one  time  this 
disease  was  common  enough.  In  the  tropics,  sporadic  cases  are  more 
numerous,  and  epidemics  more  frequent  and  extensive,  owing,  doubtless,  to 
climatic  causes,  but  partly  also  to  the  insanitary  conditions  so  generally 
prevalent  there. 

Etiology". — The  predisposing  causes  of  dysentery  include  most 
influences  that  tend  to  cause  congestion  or  debility  of  the 
alimentary  canal — irritants  of  all  sorts,  bad  food,  insufficient  food, 
purgatives,  cold,  sudden  alternations  of  temperature,  chronic  congestion 
of  the  liver  and  stasis  of  the  portal  system,  prolonged  high  temperature, 


262  GENERAL  DISEASES. 

malarial  fever,  scurvy,  constipation,  damp,  bad  water — particularly  if  bad 
from  faecal  contamination,  overcrowding  in  unhygienic  houses,  intemper- 
ance, previous  attacks. 

There  can  be  little  doubt  that  there  is  a  specific  cause  or  causes  at  the 
root  of  the  disease — a  germ  of  some  kind.  What  this  may  be  has  not 
been  definitely  settled.  Kecently  Kartulis,  Osier,  Councilman  and  Lafleur, 
and  others  have  put  forward  the  Amceba  clysenterice,  whose  connection  with 
dysentery  was  first  pointed  out  by  Loesch  in  1875,  as  the  germ  of  at 
least  one  of  the  forms  of  this  disease.  There  can  be  no  doubt  that  this 
parasite  and  the  disease  are  often  found  in  association ;  and,  further,  that 
the  amoeba  is  often  present,  not  only  in  the  dysenteric  discharges  but 
also  in  the  tissues  constituting  the  base  of  the  dysenteric  ulcer,  and  also 
in  the  contents  and  walls  of  the  frequently  associated  lesion — dysenteric 
abscess  of  the  liver.  But  it  is  equally  certain  that  the  anioeba  is  absent  in 
many  dysenteries  and  dysenteric  liver  abscesses  ;  and,  moreover,  that  it  is 
often  present  in  the  healthy  intestinal  canal,  and  in  the  complete  absence 
of  dysentery.  As  yet  the  amoeba  has  not  been  obtained  in  pure  culture ; 
consequently,  it  has  been  impossible  to  institute  experiments  on  the 
production  of  dysentery  by  material  from  which  all  other  germs  had  been 
excluded.  It  cannot,  therefore,  be  said  that  the  claims  of  the  amoeba  have 
been  scientifically  established  by  the  various  experiments  which  have  been 
made  on  the  production  of  the  diseases  in  cats  and  dogs  by  amoeba- 
containing  stools.  The  balance  of  opinion  appears  to  be  in  favour  of 
regarding  the  amoeba  as  an  epiphenomenon,  the  pre-existing  inflamed 
condition  of  the  intestine,  and  the  abnormal  nature  of  its  contents 
favouring  the  multiplication  of  a  parasite  whose  presence  may  aggravate 
lesions  which  in  the  first  instance  it  did  not  produce. 

Certain  pathologists  hold  that  the  B.  coli  commune  may  acquire 
in  some  unknown  way,  possibly  in  consequence  of  the  concurrent 
presence  of  another  bacterium,  pathogenic  and  transmissible  qualities,  and 
become  a  cause  of  dysentery.  Ogata  describes  a  minute  bacillus  in  the 
dysentery  of  Japan.  Durham  has  recently  described  another  and  still 
more  minute  bacterium  in  asylum  dysentery.  Others,  again,  regard  the 
disease  as  a  form  of  streptococcus  infection. 

In  temperate  latitudes,  dysentery  generally  shows  itself  at  the  end  of 
summer  or  beginning  of  autumn.  In  the  tropics  it  may  occur  at  any 
season,  but  most  frequently  about  the  end  of  the  rains  and  the  beginning 
of  the  dry  season  ;  that  is,  at  a  time  when  the  fluctuations  of  temperature 
are  most  marked  and  most  sudden. 

Dysentery  is  not  infectious  in  the  ordinary  sense  ;  undoubtedly,  how- 
ever, some  forms  are  communicable  through  the  intestinal  discharges,1 
either  in  drinking  water,  or  by  direct  contamination  in  common  privies, 
or  by  being  introduced  into  the  bowel  on  instruments  and  so  forth. 

The  incubation  period  has  been  stated  at  about  from  three  to  five  days 
if  infection  have  taken  place  by  the  mouth,  at  one  day  if  by  the  rectum. 
Eace  has  no  special  influence.  Both  sexes  are  equally  liable.  Children 
suffer  often  and  severely.  Occupation,  unless  in  so  far  as  it  may  entail 
special  opportunities  for  infection,  has  no  special  influence.  Pregnancy, 
childbirth,  and  miscarriage,  if  they  do  not  predispose  to  dysentery,  often 
very  much  aggravate  it,  and  are  always  grave  complications.  A  previous 
attack  confers  no  immunity ;  on  the  contrary,  it  predisposes  to  recurrence. 

Morbid  anatomy. — The  intestinal  lesions  in  dysentery,  although 
occasionally  involving  the  last  few  feet  of  the  ileum,  are  usually  confined 


DYSENTERY.  263 

to  the  large  intestine,  being  most  pronounced  in  the  sigmoid  flexure, 
or,  though  more  rarely,  in  the  csecum ;  the  transverse  colon  is  usually 
less  extensively  involved.  In  the  catarrhal  form  the  mucosa  and  sub- 
mucosa  are  congested  and  cedematous,  the  surface  softened,  perhaps 
eroded  and  covered  with  a  thick,  tenacious,  bloody  mucus.  In  the 
ulcerative  form  there  is  a  very  great  variety  of  lesion,  including  superficial 
erosions,  small  punched-out  ulcers  originating  in  inflammation  and  slough- 
ing of  the  solitary  glands,  and  larger  ulcers  of  various  shapes  and  sizes. 
The  latter  originate  from  necrosing  infiltration  of  the  mucous  membrane 
itself,  from  abscess  formation  in  the  submucosa,  and  from  fistulous  exten- 
sion in  the  latter  producing  sloughing.  The  part  of  the  mucous  membrane 
most  affected  is  the  edge  of  the  transverse  mucous  folds.  In  gangrenous 
dysentery  large  areas  of  mucous  membrane  slough  en  masse,  an  entire 
circle  of  the  bowel  being  sometimes  involved.  Dysenteric  ulcers,  as  a 
rule,  spare  the  muscular  and  serous  coats ;  at  times,  however,  these  too  are 
affected,  adhesions  to  the  neighbouring  organs  or  perforation  being  the 
result.  According  to  Councilman  and  Lafleur,  in  amoebic  dysentery  the 
elementary  lesion  is  an  abscess-like  formation  in  the  submucosa,  con- 
taining thick  gummy  material  and  many  amoebae ;  subsequently  the  mucous 
membrane  breaks  down  over  this  formation,  thereby  forming  a  character- 
istic ulcer. 

In  chronic  dysentery  the  bowel  is  occupied  by  a  larger  or  smaller 
number  of  chronic  ulcers  having  thickened  edges,  and  by  areas  of  pig- 
mented scar  tissue ;  it  may  be  variously  contracted  and  dilated  in  conse- 
quence of  different  degrees  of  narrowing  and  adhesion. 

In  acute  dysentery  the  liver  is  generally  congested,  and,  in  tropical 
countries,  is  often  (20  to  25  per  cent.)  the  seat  of  one  or  many  abscesses. 
The  mesenteric  glands  are  congested  and  swollen.  In  chronic  dysentery 
the '  liver  may  be  fatty  or  contracted ;  the  kidneys  may  be  the  subject 
of  some  form  of  chronic  nephritis ;  the  mesenteric  glands  are  hard  and 
pigmented. 

Symptoms. — It  is  customary  to  classify  dysentery  into  acute  and 
chronic.  The  acute  may  be  subdivided  into  catarrhal,  ulcerative,  and 
gangrenous.  In  actual  practice  there  is  no  hard-and-fast  line  of  distinction 
between  any  of  these  various  forms,  one  insensibly  merging  into  the 
other.  The  individual  cases  during  epidemics  have  a  tendency  to  ap- 
proximate each  other  in  type. 

A  dysenteric  attack  may  commence  suddenly,  or  it  may  supervene  on 
what  was  regarded  as  simple  diarrhoea.  In  the  latter  case  the  liquid 
motions  gradually  become  less  fsecal,  more  mucoid,  and  perhaps  bloody ; 
at  the  same  time  they  increase  in  frequency,  diminish  in  quantity,  and 
become  associated  with  griping  and  tenesmus.  On  the  other  hand,  the 
symptoms  of  dysentery  may  suddenly  supervene,  generally  during  the 
night,  without  premonitory  diarrhoea.  When  the  disease  is  fairly 
established,  the  calls  to  stool  are  frequent  or  even  incessant.  Much 
pain,  griping,  and  tenesmus  attend  the  passage  of  small  quantities  of 
glairy  mucus,  which  presently  becomes  tinged  with  blood.  Straining  to 
void  these  may  be  constant  and  extremely  painful,  and  may  be  accom- 
panied with  dysuria.  Abdominal  tenderness  and  distension  may  or  may 
not  be  marked.  Fever  may  be  entirely  absent ;  if  present,  it  is  usually  of 
a  very  mild  character,  the  thermometer  rarely  rising  above  102°  F.  The 
tongue  quickly  becomes  furred,  and  the  appetite  may  or  may  not  disappear. 
After  a  day  or  two  the  disease  rapidly  or  slowly  subsides;  or  it  may 


264  GENERAL  DISEASES. 

terminate  in  the  more  serious  manifestations  of  the  ulcerative  or  of  the 
gangrenous  form ;  or  it  may  become  chronic. 

Should  ulceration  occur,  the  stools  change  in  character  ;  they  are  still 
mucoid  and  sanguinolent,  but,  in  addition,  they  now  contain  larger  or 
smaller  flocculent  masses  of  grey,  sloughy-looking  material,  and  stink 
abominably. 

Should  gangrene  supervene,  the  stools  become  still  more  horribly  foetid, 
consisting  principally  of  a  material  like  flesh  washings.  Sometimes  large 
sloughs,  or  even  long  tubes  of  gangrenous  mucous  membrane,  are  passed. 
The  abdomen  becomes  exceedingly  tender  and  distended.  Vomiting  and 
hiccough  rapidly  supervene,  and,  as  a  rule,  death  ensues  within  a  short  time. 

When  a  catarrhal  dysentery  subsides,  the  stools  gradually  become  f aecal, 
more  copious  and  loose  ;  finally  the  looseness  subsides,  and  the  patient  may 
be  quite  well  in  the  course  of  three  or  four  days.  "When  signs  of  ulceration 
develop,  the  case  is  necessarily  more  prolonged.  Either  form  may  merge 
into  a  chronic  disease,  in  which  the  tormina  and  tenesmus,  though 
diminished,  do  not  completely  subside.  The  stools  become  feculent,  but 
they  are  rarely  properly  formed,  generally  containing  mucus  and  often 
blood,  their  passage  being  attended  with  more  or  less  griping  and  tenesmus. 
Sometimes,  though  the  stools  are  formed,  the  surface  of  the  mass  is 
coated  with  mucus ;  sometimes  they  are  partly  formed,  partly  loose  and 
mucoid ;  in  other  cases,  they  are  liquid,  feculent,  and  copious.  This  latter 
type  of  case  is  often  mistaken  for  chronic  diarrhoea.  Sometimes  con- 
stipation alternates  with  diarrhoea,  or  an  apparently  healthy  motion  is 
succeeded  by  one  composed  entirely  of  mucus  and  blood.  Every  now 
and  again,  in  consequence  of  indiscretions  in  diet,  of  cold,  of  fatigue,  or  of 
other  physiological  error,  a  more  acute  relapse  occurs.  In  this  condition, 
sometimes  better,  sometimes  worse,  the  case  may  go  on  for  months  or 
years,  the  general  health  becoming  gradually  undermined.  Dyspeptic 
conditions,  often  accompanied  by  bare  tongue  or  by  superficial  ulceration 
of  the  mouth,  supervene.  Intestinal  atrophy,  general  wasting,  oedema  of 
the  feet,  and  finally  death,  is  too  often  the  result  in  chronic  dysentery. 
Chronic  dysentery  may  not  be  of  so  urgent  and  fatal  a  character  in  every 
case,  but  at  all  times  it  is  a  grave  disease. 

Diagnosis. — Acute  dysentery  is  easily  recognised;  the  tenesmus, 
the  character  of  the  stools,  and  the  history  suffice  in  careful  hands.  In 
chronic  dysentery,  diagnosis  may  be  more  difficult ;  the  possibility  of 
haemorrhoids,  polypus,  stricture,  tuberculous,  malignant,  and  specific  disease, 
have  to  be  taken  into  account.  In  this,  as  in  all  long-standing  cases  of 
intestinal  flux,  it  is  an  excellent  rule  to  make  a  digital  examination. 

Treatment. — Best  in  bed  and  diet  are  the  most  important  matters 
in  the  treatment  of  acute  dysentery.  Eood  should  be  given  in  small 
quantities ;  it  must  be  of  a  digestible  character  and  of  a  kind  calculated  to 
produce  a  small  faecal  residuum.  Milk,  thin  chicken-tea,  egg-albumin 
water,  thin  barley  water  or  rice  water,  are  the  best  foods  during  the 
acute  stage.  They  should  be  given  in  small  quantities  at  a  time,  and 
neither  hot  nor  cold. 

There  are  three  principal  plans  of  drug  treatment  in  dysentery- 
ipecacuanha,  the  purgative  sulphates,  and  calomel. 

Ipecacuanha  is  best  given  somewhat  as  follows: — The  patient  must 
abstain  from  food  and  drink  for  at  least  three  hours.  Twenty  drops  of 
laudanum  are  then  given,  and  a  mustard  poultice  applied  to  the  epi- 
gastrium.   About  twenty  minutes  later,  20  to  30  grs.  of  powdered  ipecacu- 


LIVER  ABSCESS  OF  WARM  CLIMATES.  265 

anha  root,  either  in  bolus  or  in  a  small  quantity  of  water,  is  administered. 
The  patient  must  then  lie  flat  on  his  back  without  a  pillow,  and  endeavour 
to  avoid  vomiting ;  he  may  neither  eat,  drink,  speak,  nor  move  for  three 
or  four  hours.  If  vomiting  occur  soon  after  the  powder  is  given,  in  an  hour 
or  two  a  second  may  be  administered.  After  three  or  four  hours,  small 
quantities  of  food  may  be  given  during  the  succeeding  six  or  eight  hours, 
when  the  drugging  is  to  be  repeated.  Guided  by  its  effect,  the  use  of 
ipecacuanha  is  kept  up  for  two  or  three  days.  A  great  drawback  to  this 
treatment  is  the  severe  vomiting  which  sometimes  ensues ;  but,  notwith- 
standing this  drawback,  there  can  be  no  question  of  its  value  in  some 
cases,  although  in  others  it  appears  to  do  little  or  no  good.  If  the  ipecacu- 
anha produce  a  large,  loose,  bright  yellow  stool,  improvement  is  nearly 
sure  to  follow. 

The  sulphates,  preferably  the  sulphate  of  soda,  may  be  given  either  in 
drachm  doses  every  quarter  of  an  hour,  or  in  half -ounce  doses  every  hour, 
until  a  loose  feculent  motion  is  produced.  The  drug  should  be  continued, 
and  so  administered  as  to  secure  two  or  three  copious  loose  motions  daily. 

Calomel  is  given  either  in  5-gr.  doses  every  six  or  eight  hours,  or  in 
smaller  fractional  doses  of  a  quarter  to  half  a  grain  every  hour  for  a  short 
time ;  it  may  be  combined  with  opium  or  with  ipecacuanha. 

So  soon  as  the  stools  become  feculent  and  free  from  mucus  and  blood, 
a  mixture  of  bismuth  salicylate,  15  grs.,  and  liquor  morphinse,  5  to  10  minims, 
in  mucilage  and  water,  should  be  given  and  continued  until  the  motions 
become  solid.  Tenesmus  is  best  relieved  by  a  small  enema  of  laudanum, 
30  to  40  drops  in  2  oz.  of  starch.  Washing  out  the  rectum  with  hot 
boracic  water  is  sometimes  successful.  Hot  baths  and  hot  fomentations 
to  the  abdomen,  at  times  prove  useful. 

Chronic  dysentery  requires  very  careful  dieting,  and  often  great  variety 
of  therapeutical  treatment.  Amongst  many  measures  adopted  may  be 
mentioned  a  pure  milk  diet,  a  meat  juice  diet,  a  mixed  diet,  a  dry  diet. 
Fruit  juices  or  vegetables  ought  always  to  enter  into  the  dietary  of  long- 
standing cases.  Small  doses  of  castor-oil;  small  doses  of  ipecacuanha; 
calomel,  opium,  and  ipecacuanha  pill,  1  gr.  of  each ;  strong  decoction  of 
simaruba;  castor-oil  alternating  with  opium;  20-drop  doses  of  turpentine; 
massive  (40  oz.)  injections  of  nitrate  of  silver — half  to  one  grain  to  the  oimce ; 
injections  of  alum,  of  salicylic  acid,  of  tannin,  of  boracic  acid,  of  cold  water, 
are  some  of  the  measures  that  have  been  employed  with  more  or  less 
success.  A  sea  voyage  is  often  of  great  value.  A  course  of  Carlsbad 
water  is  also  beneficial  at  times.  Clothing  ought  always  to  be  warm. 
Alcohol,  as  a  rule,  is  badly  borne  and  aggravates  the  condition.  Exacerba- 
tions should  be  treated  with  ipecacuanha,  the  sulphates,  or  calomel.  In 
the  tropics  the  subjects  of  chronic  dysentery  should  be  sent  to  a  dry, 
temperate  climate.  The  winter  and  spring  months  in  England  do  not, 
as  a  rule,  suit  those  cases;  at  that  season  they  should  remove  to  some 
milder,  drier  climate. 

PATRICK  MAXSOX. 


LIVER  ABSCESS  OF  WARM  CLIMATES. 

A   FORM    of    suppuration    occurring    in    the    liver,    especially   in    warm 
climates,  and  almost  invariably  as  a  sequel  to  dysentery.     It   is    rarely 


266  GENERAL  DISEASES. 

idiopathic,  and  still  more  rarely  a  result  of  the  dysentery  of  temperate  or 
cold  climates. 

History  and  geographical  distribution. — Abscess  of  the  liver 
has  been  recognised  since  the  remotest  times.  Its  connection  with 
dysentery  was  indicated  by  Twining  and  Annesley  in  the  earlier  part  of 
the  present  century.  The  probability  of  its  being  caused  by  morbid 
material  conveyed' to  the  liver  from  dysenteric  conditions  of  the  colon  by 
the  portal  vein,  was  first  distinctly  formulated  by  Budd.  The  latest 
important  addition  to  our  knowledge  of  liver  abscess  was  made,  not  many 
years  ago,  by  Kartulis  in  Egypt,  who  was  the  first  to  indicate  the  occur- 
rence of  Amceba  coli  in  the  characteristic  pus. 

The  geographical  range  of  this  disease  is  regulated  by  that  of  dysen- 
tery ;  in  the  tropics,  where  dysentery  is  prevalent,  there,  as  a  rule,  liver 
abscess  is  proportionately  common.  There  can  be  no  question  of  the 
intimate  association  of  the  two  diseases,  but  the  frequency  of  this  asso- 
ciation is  not  invariably,  nor  everywhere,  nor  at  all  times  the  same. 
Some  epidemics  of  dysentery  lead  more  frequently  to  liver  abscess  than 
others,  and  the  dysentery  of  some  districts  is  more  liable  to  this  compli- 
cation than  that  of  others.  A  close  study  of  the  relative  geographical 
distributions  of  the  two  diseases  shows  that  whilst  in  many  parts  of 
Asia  and  Africa  the  greater  the  prevalence  of  dysentery  the  more  frequent 
the  occurrence  of  liver  abscess,  in  other  places,  as  in  the  West  Indies,  it 
is  not  so.  In  the  West  Indies,  although  dysentery  is  common  enough, 
liver  abscess  is  relatively  rare.  Similarly  in  temperate  climates,  as  a 
sequela  of  dysentery  contracted  in  these  climates,  liver  abscess  is  almost 
unknown.  One  or  two  epidemics  in  temperate  climates  have  been  associated 
with  a  certain  proportion  of  cases  of  liver  abscess ;  but,  as  a  rule,  in  this 
country  dysentery,  which  is  a  common  disease  at  times  in  many  of  our 
lunatic  asylums,  and  which  has  more  than  once  been  epidemic  in  some  of 
our  jails,  is  not  so  followed.  In  India,  post-mortem  examination  has  shown 
that  about  one-fifth  of  the  Europeans  who  die  of  dysentery  in  that  country 
are  the  subjects  at  the  same  time  of  liver  abscess.  The  geographical  ranges 
of  liver  abscess  and  dysentery  concur,  therefore,  only  in  warm  climates, 
and  in  them  only  to  the  extent  that  liver  abscess  is  rare  or  unknown  in 
places  where  dysentery  is  rare  or  absent. 

Etiology. — Presumably  the  real  cause  of  liver  abscess,  as  of  abscess 
elsewhere,  is  a  micro-organism  of  some  sort.  Although  many  micro- 
organisms— staphylococci,  streptococci,  B.  coli  communis,  and  other  bacteria 
— have  been  found  in  the  pus,  in  the  majority  of  instances  the  usual  pyogenic 
micro-organisms  are  absent.  According  to  my  experience,  Amceba  coli 
is  present  in  more  than  half  the  cases  of  tropical  abscess  seen  in  England ; 
in  Egypt,  according  to  Kartulis  and  others,  the  association  is  still  more 
frequent.  A  proportion  of  liver  abscesses  contain  neither  bacteria  nor 
protozoa ;  possibly,  though  present  at  one  time,  they  had  subsequently  died 
out.  Although  the  frequent  presence  of  these  organisms  in  liver  abscess 
is  undeniable,  in  view  of  their  occasional  absence,  it  cannot  be  said  that 
we  understand  their  exact  relationship  to  the  disease. 

The  adult  male  European  in  tropical  countries  is  the  principal  victim 
of  liver  abscess.  Natives,  and  European  women  and  children,  are  much 
more  rarely  attacked.  The  reason  for  this  difference  in  liability  is  not 
very  obvious ;  for,  in  the  tropics,  dysentery,  assuming  it  to  be  the  cause 
of  liver  abscess,  is  quite  as  common  in  natives  and  in  European  women  and 
children  as  it  is  in  the  European  male  adult.    It  is  generally  supposed  that 


LIVER  ABSCESS  OF  WARM  CLIMATES.  267 

the  superabundance  of  rich  food  ana  alconolic  drink  consumed  by  many 
European  male  adults  in  the  tropics  is  the  cause  of  their  superior  liability  to 
liver  abscess.  It  is  conjectured  that  in  warm  climates  conditions  of  hepatic 
congestion  are  specially  liable  to  ensue  from  such  indulgence,  and  that 
the  normal  resisting  powers  of  the  liver  to  any  organism  or  morbid 
product  that  may  be  carried  to  it  by  the  portal  vein  from  a  dysenteric 
colon  is  thereby  impaired.  There  are  two  facts  which  support  the 
idea  that  imprudence  in  eating  and  drinking  have  something  to  do 
with  the  causation  of  liver  abscess — first,  natives  who  adopt  European 
habits  as  regards  eating  and  drinking  acquire  an  enhanced  liability  to  liver 
abscess ;  second,  liver  abscess  is  comparatively  rare  in  total  abstainers. 
It  is  evident,  however,  that  other  elements  must  enter  into  the  etiological 
nexus ;  otherwise,  how  explain  the  comparative  rarity  of  liver  abscess  in 
the  West  Indies,  where  high  living  is  often  enough  combined  with  the 
tropical  heat  and  dysentery. 

Eecent  writers  declare  that  cases  of  liver  abscess  of  apparently  idio- 
pathic origin  are  attributable  to  an  actual,  though  symptomatically  latent 
dysentery.  Others  have  thrown  out  the  idea  that  both  the  liver  disease 
and  the  disease  of  the  colon  are  independent  consequences  of  the  same 
cause.  They  point  to  cases  in  which  hepatitis  seemed  to  have  preceded 
dysentery,  and  to  other  cases  in  which  attacks  of  dysentery  and  of  hepa- 
titis alternated.  For  myself,  I  have  not  yet  seen  a  case  of  tropical  liver 
abscess  in  which  a  history  of  dysentery  could  not  be  elicited.  It  should 
be  borne  in  mind  that  dysentery  is  very  often  wrongly  diagnosed  as 
diarrhoea,  and  also  that  it  may  be  entirely  overlooked. 

In  temperate  climates,  apart  from  those  suppurations  of  the  liver 
occurring  in  pysemic  conditions,  in  disease  of  the  bowel  and  of  the  gall 
bladder,  in  hydatids  and  in  other  parasitic  affections,  what  appears  to  be 
idiopathic  abscess  does  occasionally  occur. 

Liver  abscess  occurs  principally  between  the  ages  of  20  and  40.  It 
is  more  common  during  the  first  three  or  four  years  of  tropical  residence 
than  subsequently.  On  the  other  hand,  it  may  not  declare  itself  until 
after  years  of  tropical  life ;  sometimes  not  until  the  patient  has  re- 
turned to  his  native  temperate  climate.  Chills,  excesses,  local  violence — as 
a  blow,  but  particularly  chills — seem  at  times  to  have  a  marked  influ- 
ence in  determining  suppuration  in  the  liver  of  those  predisposed  to  its 
occurrence  by  an  existing  or  pre-existing  dysentery. 

Morbid  anatomy. — At  a  stage  preceding  the  actual  formation  of 
liver  abscess,  there  is  usually  to  be  found  general  congestion  and  enlarge- 
ment of  the  organ.  On  section,  one  or  more  greyish  ahsemic  patches  from 
quarter  to  one  inch  or  more  in  diameter,  having  ill-defined  borders,  and 
with  the  centre  tending  to  soften,  are  discovered.  If  these  grey  patches 
are  pressed,  a  drop  or  two  of  gummy  purulent  material  may  be  expressed. 
Later,  the  centre  of  the  patch  breaks  down,  and  a  cavity  containing  the 
characteristic  chocolate-brown,  viscid  purulage  is  formed.  This  cavity 
increases  by  degrees,  partly  by  molecular  disintegration  of  its  rough, 
ragged,  irregular  wall,  partly  by  the  falling  into  it  of  considerable  masses  of 
necrotic  tissue.  One  or  more  abscesses  may  coalesce.  There  is  no  proper 
abscess  wall ;  there  is  a  zone  of  surrounding  congestion,  but  there  is  little, 
if  any,  inflammatory  infiltration.  There  may  be  only  one  abscess,  or  there 
may  be  two  or  three,  or  a  very  large  number  (multiple  abscess  of  the  liver). 
The  individual  abscesses  vary  in  size  from  an  insignificant  cavity  to  one 
of  many  ounces  capacity,  a  whole  lobe  or  even  the  entire  organ  being, 


268  GENERAL  DISEASES. 

perhaps,  converted  into  a  huge  pus  sac.  "When  the  abscess  becomes 
encysted  (a  rare  event),  the  wall  of  the  sac  is  converted  into  a  thick,  tough, 
fibrous  membrane  which  completely  shuts  off  the  cavity  from  the  rest  of 
the  organ.  In  time  the  fluid  part  of  the  contents  may  be  absorbed,  a 
cretaceous  or  cheesy  mass  remaining.  When  liver  abscess  approaches 
the  surface  of  the  gland,  the  implicated  peritoneal  surfaces  inflame  and 
generally  become  adherent. 

Symptoms. — These  vary  very  much  both  in  character  and  intensity. 
As  a  rule,  at  the  commencement  they  do  not  appear  to  be  proportionate 
to  the  importance  of  the  organ  involved  or  to  the  gravity  of  the  disease. 
In  some  cases  the  oncoming  of  abscess  is  attended  with  all  the  signs  of 
suddenly  developed,  acute  inflammation,  or  congestion  of  the  liver.  In 
such  there  may  be  stabbing  pain  in  the  right  side  in  the  region  of  the 
liver.  The  pain  is  greatly  aggravated  by  the  movements  of  respiration, 
by  coughing,  sneezing,  and  the  like.  There  is  a  sense  of  weight  and 
fulness  in  the  right  hypochondrium ;  possibly  there  is  severe  pain  or 
aching  in  the  right  shoulder;  often  there  is  a  short,  dry  cough.  The 
tongue  is  foul ;  anorexia  is  complete ;  fever  may  run  high.  On  examina- 
tion,- it  will  be  found  usually  that  the  respiratory  movements  on  the 
affected  side  are  restricted,  the  right  rectus  tense,  and  perhaps  the  corre- 
sponding leg  drawn  up.  Firm  palpation  and  percussion  over  the  liver 
give  great  pain.  There  is  general  increase  in  the  size  of  the  organ  both 
upwards,  downwards,  and  transversely.  With  or  without  the  occurrence 
of  rigor,  which  may  be  very  violent,  the  fever  gradually  merges  into  the 
hectic  type,  temperature  being  normal,  or  nearly  so,  in  the  early  part  of 
the  day,  and  high — 102°  to  103° — in  the  evening.  Profuse  sweating  now 
occurs,  especially  during  the  night,  or  whenever  the  patient  falls  asleep. 
Bulging  of  some  part  of  the  hepatic  area  may  develop  and  be  apparent 
to  the  eye,  or  ascertainable  by  percussion  or  palpation.  The  patient,  as 
a  rule,  lies  on  his  back  or  on  his  right  side ;  in  some  rare  instances  he 
may  rest  more  comfortably  on  his  left  side. 

In  other  and  in  the  majority  of  cases  there  may  be  no  such  dramatic 
commencement  of  the  disease,  the  patient  not  being  able  to  say  exactly 
when  his  disease  began.  He  gradually  loses  health ;  is  languid ;  suffers 
from  anorexia ;  has  a  foul  tongue ;  has  constipated  or  irregular  bowels ; 
sometimes  he  may  vomit  or  show  other  symptoms  of  gastric  and  intestinal 
catarrh.  He  may  or  he  may  not  have  pain  and  sense  of  weight  or  fulness 
about  the  liver.  If  the  thermometer  be  used,  it  will  be  found  that  tem- 
perature rises  towards  evening  to  101°  or  102°,  the  rise  being  sometimes 
preceded  by  slight  or  more  marked  shivering.  Profuse  sweating  during 
the  night  is  nearly  a  constant  occurrence.  On  examination,  the  liver  is 
found  enlarged,  although  not  necessarily  to  a  very  great  extent;  the 
enlargement  may  be  general  or  it  may  be  localised. 

When  abscess  has  formed,  the  following  symptoms — some  or  all  of  them 
— are  generally  to  be  found: — A  low  morning  and  high  evening  (101°- 
103°)  temperature;  profuse  nocturnal  sweating;  a  rapid,  feeble  pulse; 
wasting ;  generally  a  foul  tongue ;  anorexia ;  a  muddy  complexion ;  languor ; 
sleeplessness ;  great  depression  of  spirits,  and  usually  irritability  of  temper. 
Locally  we  may  find  enlargement  of  the  liver ;  tenderness  at  one  or  more 
points ;  fulness  of  the  right  side  and  epigastrium ;  obliteration  of  one  or  more 
intercostal  spaces ;  perhaps  a  rounded  swelling.  To  these  are  sometimes 
added  dry  cough,  rigid  right  rectus  muscle,  pain  in  the  right  shoulder, 
dorsal  or  right-side  decubitus,  very  rarely  jaundice  or  splenic  enlargement. 


LIVER  ABSCESS  OF  WARM  CLIMATES.  269 

As  the  disease  advances  the  symptoms  become  more  definite,  wasting 
is  progressive,  debility  extreme.  There  may  be  oedema  of  the  feet,  diar- 
rhoea, etc.  If  not  relieved  by  surgical  means,  the  case  terminates  either 
in  death  from  exhaustion,  or  in  rupture  of  the  abscess  through  the  lung, 
the  characteristic  chocolate-coloured  viscid  pus,  mixed  with  blood,  being 
expectorated ;  or  into  the  pleura,  the  stomach,  the  intestine,  the  peritoneal 
cavity,  or  externally.  In  a  very  few  instances  liver  abscess  has  burst  into 
the  pericardium,  gall  ducts,  pelvis  of  the  right  kidney,  into  the  vena  cava, 
or  other  large  vessel.  Occasionally  the  abscess  becomes  encysted ;  in  this 
event  constitutional  symptoms  subside,  and  the  patient  recovers. 

When  rupture  takes  place  into  the  right  lung,  the  most  frequent 
direction,  there  may  be  a  sudden  gush  of  pus  which  floods  the  bronchial 
tubes  and  almost  suffocates  the  patient;  or  the  contents  of  the  abscess 
may  be  coughed  up  more  gradually.  In  either  event,  in  about  half  of 
these  cases,  recovery,  rapidly  or  more  slowly,  ensues.  On  the  other  hand, 
hectic  symptoms  may  continue,  and,  after  weeks  or  months,  a  certain 
amount  of  pus  being  brought  up  daily,  or  at  intervals,  the  patient  suc- 
cumbs from  slow  exhaustion.  When  rupture  takes  place  into  the  right 
pleura,  the  physical  symptoms  of  pleuritic  effusion  are  rapidly  developed. 
When  rupture  occurs  into  the  stomach,  the  escaping  pus  may  be  got  rid 
of  by  vomiting;  if  into  the  bowel,  it  may  be  voided  as  a  diarrhcea-like 
motion. 

Diagnosis. — This  rests  principally  on  the  following  points : — 
(1)  Eesidence,  present  or  past,  in  a  tropical  climate;  (2)  a  history  of 
dysentery ;  (3)  the  occurrence  of  a  more  or  less  distinct  evening  rise  of 
temperature ;  (4)  enlargement  of  the  liver ;  (5)  pain  or  discomfort  in  this 
organ.  Such  an  assemblage  justifies  a  suspicion  of  abscess.  If  bulging  of 
one  or  more  intercostal  spaces,  tenderness  on  pressure  over  a  particular 
spot,  friction  (pleuritic  or  peritoneal),  or  a  limited  and  rounded  swelling 
continuous  with  the  liver  dulness ;  if  all  or  any  of  these  are  present,  the 
diagnosis  of  liver  abscess  is  so  likely  to  be  correct  that  exploratory 
aspiration,  with  a  view  of  confirming  or  possibly  refuting  it,  should  be  had 
recourse  to.  In  all  cases  in  which  liver  abscess  is  strongly  suspected, 
exploration  with  the  aspirator  should  be  practised  with  as  little  delay  as 
possible,  the  surgeon  being  prepared  to  operate  at  once  if  pus  is  found. 
Exploration  should  be  made  under  chloroform.  The  point  selected  for 
entering  the  needle  may  be  indicated  by  swelling,  tenderness,  or  fixed 
pain.  Failing  such  a  guide,  a  point  in  an  intercostal  space  close  to  the 
edge  of  the  ribs  and  slightly  in  advance  of  the  midaxillary  line  should  be 
selected.  The  exploring  needle,  which  must  not  be  too  small,  should  be 
thrust  inwards  and  somewhat  upwards,  and  to  its  full  extent  if  pus  is 
not  found  nearer  the  surface.  If  the  abscess  be  not  struck,  there  should 
be  no  hesitation  in  re-entering  the  needle  at  various  points  of  the  area  of 
dulness.  If  necessary,  every  part  of  the  organ  should  be  freely  explored, 
as  far  as  anatomical  considerations  render  it  practicable.  There  is  little 
danger  attending  this  operation ;  there  is  much  greater  danger  in  neglect- 
ing or  postponing  it.  As  a  guide,  the  fact  that  the  majority  of  liver 
abscesses  occur  in  the  upper  and  back  part  of  the  right  lobe,  has  to  be 
borne  in  mind. 

The  fever  attending  liver  abscess  is  often  mistaken  for  malarial  inter- 
mittent ;  but  the  history  of  the  case,  the  absence  of  considerable  splenic 
enlargement,  the  absence  of  the  plasmodium  from  the  blood,  and  the 
uselessness  of  quinine,  should  obviate  this  mistake.     Syphilitic  disease  of 


270  GENERAL  DISEASES. 

the  liver,  leucocythaeniia,  pernicious  anaemia,  gallstones,  suppurating 
hydatids,  may  each  be  attended  with  fever  and  enlargement  of  the  liver, 
and  require  to  be  considered  in  attempting  diagnosis.  It  sometimes 
happens  that  the  pleuritic  and  pneumonic  symptoms  which  affect  the  base 
of  the  right  lung  in  suppurating  hepatitis,  and  which  so  often  precede 
rupture  of  an  abscess  through  the  lung,  are  misinterpreted,  and  the 
attendant  liver  abscess  ignored.  Such  an  error  can  best  be  avoided  by 
careful  inquiry  into  the  history,  and  careful  physical  examination.  A 
history  of  antecedent  dysentery,  followed  after  a  variable  time  by  hectic 
fever  and  subjective  and  objective  symptoms  referable  to  the  right  side 
generally,  indicate,  almost  invariably,  abscess  of  the  liver. 

Prognosis. — In  simple  abscess  of  the  liver,  which  has  been  operated 
on  early,  the  prognosis  is  good.  In  multiple  abscess,  which  is  generally  to 
be  suspected  if  fever  does  not  subside  after  free  drainage,  prognosis  is 
bad.  Spontaneous  opening  of  abscess  through  the  skin  or  lung  leads  to 
recovery  in  about  half  the  cases.  Rupture  into  the  alimentary  canal  is 
not  so  favourable;  if  into  the  peritoneum,  pericardium,  or  into  a  blood 
vessel,  it  is  almost  necessarily  fatal. 

Treatment. — When  hepatitis  declares  itself,  and  before  suppuration 
has  taken  place,  the  patient  should  be  sent  to  bed,  placed  on  very  low  slop 
diet,  and  freely  purged  with  sulphate  of  soda.  Sometimes  a  full  dose  of 
ipecacuanha,  as  in  dysentery,  is  useful.  At  the  same  time,  large  hot  poul- 
tices should  be  laid  over  the  region  of  the  liver  and  frequently  renewed. 
If  it  is  believed  that  suppuration  has  occurred,  the  liver  must  be  explored 
at  once ;  if  an  abscess  is  struck,  it  should  be  opened  and  thoroughly 
drained.  Diet  must  now  be  more  nutritious ;  at  the  same  time  it  should  be 
unstimulating.  Aspiration  often  does  much  good,  even  if  no  abscess  is 
discovered,  a  fact  which  encourages  its  early  employment.  If  temperature 
does  not  fall  within  a  few  days  of  opening  an  abscess,  and  if  drainage  be 
satisfactory,  a  second  abscess  may  be  suspected,  and  should  be  sought  for. 

If,  after  rupture  into  the  lung  or  elsewhere,  the  patient  remain  hectic 
and  continue  to  lose  flesh,  and  whether  he  is  or  is  not  expectorating  pus, 
an  attempt  should  be  made  to  reach  and  drain  the  abscess  from  the  out- 
side. Not  unfrequently  in  such  cases  a  subsidiary  abscess  forms  above 
the  diaphragm  through  which,  by  means  of  a  small  sinus,  it  communicates 
with  the  original  abscess  in  the  liver ;  if  feasible,  this  pulmonary  abscess 
should  be  drained. 

PATEICK  MANSON 


MEDITERRANEAN  EEVER. 

A  specific  fever  occurring  on  the  shores  of  the  Mediterranean, 
and  possibly  elsewhere.  It  is  characterised  by  a  long  and  indefinite 
course  of  several  weeks'  or  months'  duration,  made  up  usually  of  alternat- 
ing waves  of  exacerbations  and  remissions,  profuse  perspirations,  anamiia, 
liability  to  rheumatic-like  affection  of  the  joints,  neuralgia,  orchitis,  etc., 
and  distinguished  pathologically  by.  the  presence  of  a  specific  micro- 
organism in  a  somewhat  enlarged  spleen. 

History  and  geographical  distribution. — For  many  years 
this  disease  was  confounded  both  with  enteric  and  with  malarial  fever. 
Marston,  in   1861,  was  the  first  to  recognise  its  special  nature,  and  to 


MEDITERRANEAN  FE  VER.  2  7 1 

correctly  describe  its  clinical  features.  In  18S7,  Bruce  established  its 
specific  character  by  demonstrating  its  dependence  on  a  bacterium — 
Micrococcus  mclitcnsis. 

So  far  as  is  definitely  known,  the  disease  is  confined  to  the  Mediter- 
ranean ports,  where  it  passes  by  a  variety  of  local  names,  of  which  Malta 
fever  and  Eock  (Gibraltar)  fever  are  best  known  to  English  readers.  Possibly 
the  same  disease  occurs  on  the  shores  of  the  Eed  Sea,  in  India,  the  West 
Indies,  and  elsewhere  in  the  tropics  and  sub-tropics.  It  is  one  of  the 
most  frequent  causes  of  invaliding  in  the  garrisons  at  Malta  and  Gibraltar. 

Etiology. — Mediterranean  fever  is  not  directly  communicated 
from  person  to  person.  In  Malta  and  Gibraltar  its  prevalence  is  found  to 
be  in  inverse  ratio  to  the  monthly  rainfall,  occurring  mostly  during  the 
dry  hot  weather  from  May  to  September,  and  being  most  common  in  dry 
years.  The  water  and  food  supply  have  no  manifest  influence.  The 
infection  is  generally  believed  to  be  air-borne,  and  to  proceed  from  sewage- 
saturated  foci.  Certain  spots,  owing  to  their  proximity  to  certain  drains, 
are  specially  infective. 

From  15  to  40  is  the  most  susceptible  age.  "Women  are  more  liable 
than  men.  All  conditions  of  life  are  subject  to  the  disease.  Length  of 
residence  has  no  immunising  effect.  It  is  probable  that  one  attack  confers 
a  temporary,  but  not  an  absolute  or  permanent  protection. 

Careful  bacteriological  studies  by  Bruce,  Gipps,  Hughes,  and  Wright 
make  it  in  the  highest  degree  probable  that  this  disease  is  the  result  of 
invasion  of  the  spleen  by  the  bacterium  already  referred  to.  The  M.  meli- 
tensis  can  be  cultivated  and  isolated.  On  injection  of  a  pure  culture 
into  a  monkey,  fever — similar  to  that  occurring  in  man — ensues.  The 
bacterium  can  be  recovered  from  the  monkey  and  recultivated ;  on 
subsequent  injection  into  a  second  monkey  it  will  again  produce  the 
disease. 

Morbid  anatomy. — Hughes  reports  that  in  sixty  post-mortem 
examinations,  pulmonary  congestion,  generally  with  pneumonic  consolida- 
tion and  with  injection  of  the  bronchi,  was  present  in  87  per  cent.  The 
heart  is  pale  and  flabby.  Patchy  congestion — not  involving  Peyer's 
patches — and,  though  less  frequently,  a  peculiar  cedematous  swelling  of 
the  intestinal  mucosa,  occur  in  the  majority  of  cases.  The  liver  may  be 
congested.  The  spleen  is  always  enlarged,  congested,  soft,  friable,  often 
diffluent,  and  weighs  from  15  to  19  oz.  The  kidneys  are  also  congested. 
The  microscopical  appearances  of  the  various  organs  are  such  as  may  be 
expected  in  any  case  of  severe  and  protracted  fever. 

Symptomatology. — Hughes,  who  writes  from  an  experience  of 
upwards  of  one  thousand  cases,  after  remarking  on  the  variability  of 
the  symptoms,  and  after  putting  aside  the  milder  and  indefinite  cases, 
classifies  the  types  of  Mediterranean  fever  into  undulatory,  intermittent, 
malignant. 

The  undulatory  type. — In  this  there  is  a  gradual  step-like  rise  of 
temperature  until  104°  or  105°  F.  is  attained,  with  slight  morning  remissions 
and  evening  exacerbations,  together  with  increasing  gastric  symptoms, 
constipation,  general  pains,  and  headache.  Some  pulmonary  congestion 
or  catarrh  now  shows  itself.  After  a  week  or  longer  the  fever  and  other 
symptoms  begin  to  abate  in  the  same  gradual  manner  as  they  arose,  the 
daily  remissions  being  accompanied  by  profuse  sweats.  When  temperature 
has  been  normal,  or  nearly  so,  for  a  few  days,  the  gradual  step-like  rise  of 
temperature  and  gradual  step-like  fall,  accompanied  by  the  same  symptoms. 


2 72  GENERAL  DISEASES. 

are  repeated.  Relapse  again  occurs ;  and  so  on,  in  a  succession  of  alternat- 
ing waves  of  fever  and  apyrexia,  the  disease  continuing  for  an  indefinite 
period  of  weeks  or  months.  The  length  of  one  of  the  constituent  waves 
varies  from  one  to  five  weeks,  the  average  being  about  ten  days.  The  recur- 
ring relapses  tend  to  become  progressively  shorter  and  milder ;  anaemia  and 
wasting  advance,  however,  and  may  reach  a  high  degree.  The  more  general 
symptoms  are  often  associated  with  neuralgia  of  various  nerves,  often  with 
sudden  effusions  of  a  metastatic  and  fleeting  nature  into  various  joints,  with 
orchitis,  bronchial  catarrh,  lobular  pneumonia,  palpitations,  rheumatic  and 
other  complications.  After  two  or  three  months,  temperature  becomes 
permanently  normal,  and  then  slow  convalescence,  easily  interrupted,  sets 
in.  The  average  duration  of  the  disease  from  first  to  last  is  from  sixty 
to  seventy  days ;  but  it  may  be  very  much  longer,  sometimes  a  year  or  even 
more. 

The  intermittent  type. — In  this  the  daily  fluctuations  of  temperature 
are  more  marked,  the  chart  being  like  that  of  hectic ;  at  the  same  time  a 
tendency  to  waves  of  increase  and  decrease  of  pyrexia,  and  a  liability  to 
similar  complications  as  in  the  undulatory  type,  are  observable. 

The  malignant  type. — The  patient,  after  four  or  five  days  of  rapidly 
intensifying  severe  febrile  distress,  with  well-marked  gastric  and  intestinal 
disturbances,  slight  splenic  enlargement,  hepatic  and  epigastric  tenderness, 
diarrhoea,  and  a  temperature  of  from  104°  to  107°  F.,  shows  pronounced 
signs  of  pulmonary  congestion  and  general  bronchitis.  Later,  the  fever 
continuing,  the  tongue  dries,  the  mind  becomes  clouded,  and  the  typhoid 
state  is  established.  Fatal  hyperpyrexia  (110°  to  115°  F.)  may  then 
develop,  or  cardiac  failure  may  occur,  the  patient  dying  any  time  during 
the  first  (137  per  cent.),  second  (18-3  per  cent.),  third  (25  per  cent.),  or 
fourth  week,  or  even  later.  There  may  be  one  or  more  temporary  abate- 
ments of  fever,  as  in  the  preceding  types,  with  subsequent  and  fatal 
relapse. 

Special  symptoms  of  more  or  less  frequent  occurrence  are  de- 
squamation, most  noticeable  on  the  soles  of  the  feet,  occurring  about  the 
fourth  week ;  falling  of  the  hair,  especially  in  protracted  attacks ;  slight 
bronzing  of  skin ;  a  peculiar  odour  emitted  by  the  patient's  body ;  pro- 
fuseness  of  diaphoresis,  particularly  marked  in  the  intermittent  cases ; 
presence  of  pronounced  rigors ;  the  anaemia ;  oedema  of  ankles  during  con- 
valescence ;  absence  of  organisms  in  the  general  circulation ;  slight  but 
distinct  swelling  of  the  spleen ;  slighter  or  graver  pulmonary  complications 
in  about  95  per  cent,  of  cases ;  occasionally  pleurisy ;  gastric  symptoms 
such  as  anorexia,  foul  tongue,  epigastric  tenderness ;  constipation  (81  per 
cent.) ;  diarrhoea  (-1  per  cent)  ;  occasionally  epistaxis. 

Among  the  symptoms  referable  to  the  nervous  system,  headache  and 
shifting  pains  in  back  and  limbs  are  prominent  during  the  early  stages. 
Later,  there  may  be  facial  or  occipital  neuralgia,  lumbago,  sciatica, 
intercostal  neuralgia,  cutaneous  hyperaesthesia  (especially  of  the  soles), 
insomnia,  delirium,  and  other  mental  disturbances,  and  occasionally  though 
rarely  paresis  with  atrophy  of  certain  muscles. 

Joint  effusions,  especially  in  the  rheumatic,  are  a  common  characteristic 
during  or  after  the  third  week.  They  may  come  and  go  suddenly,  and  are 
attended  with  great  pain ;  redness  of  the  part  is  uncommon.  These 
effusions  do  not  eventuate  in  ankylosis.  Acute  epididymitis  and  orchitis 
occasionally  supervene. 

Diagnosis. — This  is  often  a  matter  of  great  difficulty ;  typhoid  fever, 


MEDITERRANEAN  FE  VER.  2  7  3 

malaria,  rneumatic  fever,  tuberculosis,  and  septic  conditions  being  all  more  or 
less  simulated  by  this  disease.  The  occurrence  of  alternating  pyrexia!  and 
apyrexial  waves,  of  profuse  diaphoresis,  of  the  rheumatic-like  affection  of 
joints;  together  with  absence  of  rash,  of  diarrhoea,  of  dry  tongue,  of 
haemorrhages,  of  typhoid  serum  reaction,  and  of  Ehrlich's  rose-red  urine 
reaction,  and  considerations  of  season  and  place,  should  aid  in  the  diagnosis 
from  typhoid.1  Malaria  is  more  easily  excluded  by  a  microscopical  ex- 
amination of  the  blood  and  by  the  quinine  test ;  rheumatic  fever  by  the 
impotence  of  the  salicylates ;  tuberculosis  by  the  absence  of  the  bacillus ; 
septic  conditions  by  the  absence  of  evidence  of  septic  foci  such  as  ulcer- 
ative endocarditis,  abscess  in  the  liver,  or  pus  formation  elsewhere. 

Prognosis. — Considering  the  length  and  severity  of  the  disease,  the 
danger  to  life  is  small.  The  mortality  in  those  attacked  is  under  two  per 
cent.  So  far.  as  invaliding  is  concerned,  the  prognosis  is  not  favourable, 
ninety  days  being  the  average  time  on  the  sick  list.  Complications,  but 
particularly  a  tendency  to  hyperpyrexia,  should  lead  to  a  very  guarded 
prognosis. 

Treatment. — Prophylactic  measures  should  be  based  on  the  faecal 
origin,  and  on  the  air-borne  character  of  the  virus.  They  must  there- 
fore include  avoidance  of  soil  pollution,  a  perfect  system  of  drainage, 
efficient  sewer  ventilation,  and  abundant  flushing  with  water.  As  a 
precautionary  measure,  Mediterranean  towns  should  be  avoided,  if  pos- 
sible, from  June  to  October — the  season  of  greatest  prevalence  of  Medi- 
terranean fever. 

The  treatment  of  this  disease  is  more  a  matter  of  nursing,  feeding,  and 
patience  than  of  drugs ;  there  is  no  specific.  As  a  primary  and  essential 
measure,  the  patient  should  be  removed  from  the  spot  in  which  the  disease 
was  contracted.  He  ought  to  be  confined  to  bed  and  placed  on  a  fluid 
diet,  of  which  milk  and,  in  the  absence  of  diarrhoea,  animal  broths  are  the 
more  important  elements.  Fruit  juices,  as  freshly-made  lemonade,  should 
always  be  prescribed :  this  measure  has  to  be  specially  attended  to,  since 
in  the  absence  of  all  vegetables  from  a  dietary  which  may  have  to  be 
adhered  to  for  several  consecutive  months,  scorbutus  might  very  well 
ensue.  In  view  of  the  profuse  sweating  and  consequent  liability  to  chill, 
the  patient  should  sleep  in  flannel.  Constipation  may  be  treated  by 
enemata  or  by  mild  aperients ;  diarrhoea,  if  present,  by  avoiding  animal 
broths  and  by  the  use  of  small  quantities  of  opium  or  other  astringents. 
Stimulants  may  have  to  be  given;  unless  definitely  indicated,  they  are, 
perhaps,  better  avoided.  Sleeplessness  may  require  opiates,  sulphonal  or 
bromides ;  headache  yields  to  antipyrine.  This  last  drug,  in  view  of  its 
depressing  effect,  must  be  used  with  caution,  particularly  in  the  later 
stages  of  the  disease,  when  there  is  much  cardiac  debility.  Swollen 
and  painful  joints  indicate  hot  fomentations,  belladonna  applications,  and 
wrapping  in  cotton-wool.  If  temperature  runs  high — above  103° — tepid 
or  cold  sponging  may  be  used ;  if  there  be  actual  hyperpyrexia,  the  cold 
bath  must  be  employed  promptly  and  thoroughly. 

Eeturn  to  ordinary  diet  may  be  attempted  only  when  the  tongue  is 
clean ;  even  then  the  resumption  of  solid  food  should  be  made  with  the 
greatest  care.  Tonics,  wine,  beer,  and  change  of  air  are  useful  during 
convalescence.    Quinine  does  harm  in  the  early  stages ;  later,  in  small  doses, 

1  Wright  and  Semple  state  that  the  blood  serum  in  Mediterranean  fever  gives  a  characteristic 
clumping  reaction  with  cultures  of  M.  melitensis,  an  observation  which  more  recent  experience 
has  confirmed. 

VOL.  I. 18 


274  GENERAL  DISEASES. 

it  is  beneficial  as  a  stomachic  and  tonic.     The  anaemia  indicates  iron  and 
arsenic. 

During  autumn  and  winter,  it  is  not  advisable  to  send  patients  home 
to  the  cold  of  England ;  if  the  return  can  be  made  in  summer,  it  is  to 
be  advised,  provided  in  other  respects  the  patient  is  able  for  the  journey. 

PATRICK  MAXSOX 


SPRUE. 

A  disease  of  warm  climates,  characterised  by  irregular  action  of  the 
bowels  ;  profuse  fluid  or  pultaceous,  pale,  frothy  stools  ;  flatulent  dyspepsia ; 
and,  very  generally,  a  raw,  eroded  condition  of  the  mucous  membrane  of 
the  tongue,  mouth,  and  gullet.  It  runs  a  chronic  course ;  is  subject  to 
exacerbations  and  remissions ;  and,  if  unchecked,  terminates  in  atrophy  of 
the  gastric  and  intestinal  mucosa,  general  wasting,  and  death. 

History  and  geographical  distribution. — The  type  of  case 
which  in  recent  years  has  come  to  bear  the  name  "  sprue,"  was  more  or  less 
clearly  recognised  by  the  earlier  writers  on  tropical  diseases,  being  described 
by  them  as  "  tropical  diarrhoea,"  or  under  some  such  indefinite  and  perhaps 
misleading  term;  but  it  is  only  recently  that  this  disease  has  attracted  much 
attention,  and  been  recognised  as  possessing  characters  of  a  kind  more 
or  less  specific.  It  is  probable  that  sprue  exists  in  all  tropical  and  sub- 
tropical climates.  Although  the  first  clear  description  of  the  disease 
(Hillary's)  applied  to  the  West  Indies,  it  is  principally  from  China,  the 
Eastern  Peninsula,  the  islands  of  the  Eastern  Archipelago,  and  from  India 
that  modern  accounts  emanate. 

Etiology. — The  specific  cause,  if  such  exist,  is  unknown.  The 
principal  predisposing  cause  is  undoubtedly  residence,  particularly,  though 
not  necessarily  prolonged,  residence  in  a  tropical  or  subtropical  chmate. 
Sprue  is  apt  to  supervene  on  dysentery,  diarrhoea  (especially  the  morning 
diarrhoea  of  the  tropics),  prolonged  lactation,  frequently -recurring  preg- 
nancies, miscarriage,  uterine  haemorrhages,  malarial  fevers,  and  other 
causes  of  debility,  especially  those  associated  with  disease  of  the  alimentary 
canal.  In  some  instances,  apart  from  tropical  residence,  neither  predispos- 
ing nor  exciting  cause  can  be  traced.  Although  residence  at  some  time  in 
a  warm  chmate  is  a  necessary  condition,  the  disease  may  not  declare  itself 
until  the  patient  has  returned  to  the  temperate  zone. 

Both  sexes  are  liable.  Sprue  is  not  reported  as  occurring  in  children. 
It  is  rare  in  natives,  being  principally  confined  to  Europeans.  Rich  and 
poor,  temperate  and  intemperate,  are  alike  liable. 

Morbid  anatomy  and  pathology. — Post-mortem,  the  aliment- 
ary canal  is  found  so  thinned  as  to  be  almost  diaphanous.  A  viscid, 
dirty  grey  mucus  coats  its  inner  surface.  When  this  is  washed  away, 
points,  patches,  and  large  areas  of  injection  and  erosion  are  seen  in  the 
subjacent  mucous  membrane.  The  villi,  follicles,  and  glands  in  many 
places  are  atrophied  or  completely  destroyed.  Small  pigmented  cicatricial 
patches  may  be  visible  here  and  there.  On  microscopical  examination  of 
sections,  besides  the  destruction  of  villi  and  glands,  fibrotic  changes  in  the 
submucosa  are  usually  very  manifest.  The  oesophagus  may  be  implicated 
as  well  as  the  stomach  and  intestine.  Sometimes  deeper  ulceration  is  met 
with,  especially  in  the  lower  part  of  the  ileum  and  in  the  great  intestine. 


SPRUE.  275 

Inflammation,  as  well  as  degenerative  changes  in  the  acini  of  the  pancreas, 
have  been  reported.  Beyond  these,  and  general  dryness  and  wasting  of  all 
the  tissues  of  the  body,  there  appears  to  be  no  other  lesion  peculiar 
to  sprue. 

In  the  absence  of  all  knowledge  as  to  the  special  cause  of  this  disease, 
we  must  regard  sprue  as  the  result  of  some  incapacity  of  the  European 
constitution  to  withstand  tropical  climates  and  morbid  influences,  para- 
sitic or  other,  occurring  there — an  unsuitability  which  renders  the 
European  prone  to  a  chronic  form  of  gastro-intestinal  catarrh,  and  possibly 
to  exhaustion  of  the  glandular  structures  appertaining  to  the  digestive 
system.  The  absence  of  bile  from  the  stools,  and  the  enormous  bulk  of  the 
latter,  suggest  that  in  some  way  the  intestinal  and  digestive  juices  are 
deficient,  as  if  from  exhaustion  of  the  glands.  Very  probably  the  decom- 
position of  undigested  food  has  something  to  do  with  the  irritative  lesions 
which  are  so  prominent  a  feature  at  post-mortem  examinations. 

Symptoms. — The  subject  of  sprue  generally  gives  a  history  of  gradu- 
ally increasing  diarrhoea.  In  a  few  instances  the  onset  may  be  more  sudden. 
As  a  rule,  however,  at  first  the  diarrhoea  occurs  only  in  the  morning  and 
forenoon,  the  two  or  three  loose  and  somewhat  copious  stools  which  are 
then  passed  being,  perhaps,  for  a  time  bilious  in  character.  By  degrees,  or 
more  suddenly,  the  motions  become  more  numerous,  more  profuse,  and  are 
now  observed  to  be  singularly  pale,  frothy,  and  fermenting,  sometimes 
pultaceous,  always  strikingly  excessive  in  amount.  At  the  same  time, 
dyspeptic  distension,  especially  after  food,  is  troublesome,  and  there  is 
developed  a  characteristic  inflamed  condition  of  the  mouth  and  pharynx. 

The  disease  is  subject  to  exacerbation  and  remission;  rarely  is  it 
altogether  in  abeyance.  During  the  exacerbations  the  mucous  membrane 
of  the  tongue,  of  the  floor  of  the  mouth,  of  the  cheeks  and  lips  (particularly 
where  they  are  in  contact  with  the  teeth),  and  of  the  palate  and  pharynx, 
is  seen  to  be  congested  and  raw-looking,  the  edges  of  the  tongue  being 
thrown  into  transverse  folds.  Here  and  there  eroded  patches,  sometimes 
minute,  sometimes  more  extensive,  often  covered  with  a  viscid  coating  of 
muco-pus,  are  discoverable.  The  whole  of  the  mouth  is  exquisitely 
sensitive,  so  that  only  the  very  blandest  foods  can  be  taken.  Owing  to 
the  attendant  irritation,  a  large  quantity  of  saliva  is  secreted,  and  is  con- 
tinually being  swallowed,  or,  when  swallowing  is  very  painful,  being 
allowed  to  dribble  from  the  corners  of  the  mouth.  From  time  to  time  this 
acute  phase  subsides,  and  then  the  tongue  is  seen  to  be  if  anything  rather 
small ;  it  is  clean,  bare,  apparently  devoid  of  fur  and  papillae,  and  glossy  as 
if  covered  with  thin  varnish.  Though  less  sensitive  in  this  condition  than 
when  eroded,  it  is  still  over-sensitive.  During  the  exacerbations  especially, 
and  doubtless  in  consequence  of  a  similarly  inflamed  eroded  condition  of 
the  pharynx  and  oesophagus,  swallowing  is  painful ;  and  there  may  be  also 
a  sense  of  heat  or  rawness  under  the  sternum.  Vomiting,  without  much 
nausea,  is  not  an  unusual  occurrence. 

By  degrees  the  patient  loses  weight,  becomes  anaemic,  irritable,  and 
weak  both  mentally  and  physically.  The  skin  acquires  a  dark,  muddy, 
dry,  lustreless  appearance,  and  hangs  in  loose  folds  on  the  wasted  body  and 
limbs.  The  liver  partakes  in  the  general  wasting,  yielding  only  a  narrow 
percussion  area  suggestive  of  cirrhosis.  From  time  to  time,  as  the  disease 
advances,  the  patient  may  be  confined  to  the  house,  or  even  to  bed,  from 
the  urgency  of  the  diarrhoea  and  attendant  prostration.  Cold — especially 
cold  and  damp — or  very  hot   weather,   mental   worry,    or  the   slightest 


276  GENERAL  DISEASES. 

indiscretion  in  food,  aggravate  all  the  symptoms.  In  this  way  the  case 
goes  on  for  months  and  years ;  one  month  a  little  better,  the  next  a  little 
worse ;  on  the  whole  losing  ground.  Finally,  unless  properly  treated,  and 
treated  at  a  sufficiently  early  stage,  the  patient  dies  either  from  some  inter- 
current disease,  from  sudden  profuse  diarrhoea,  or  from  exhaustion ;  in  the 
latter  case  oedema  of  the  feet  and  legs  usually  preceding  the  fatal  event. 

"With  care  sprue  may  remain  in  abeyance  for  years,  relapse  and  recovery 
alternating  from  time  to  time.  In  some  cases,  under  treatment,  diarrhoea 
and  sore  mouth  subside,  but  the  stools  continue  amazingly  excessive  in 
quantity  and  devoid  of  colour ;  such  cases,  notwithstanding  the  cessation 
of  diarrhoea,  die.  Minor  degrees  of  sprue  are  also- seen,  in  which  a  liability 
to  sore  mouth  and  morning  diarrhoea  of  pale  stools  may  continue  for  years, 
without,  apparently,  seriously  impairing  the  general  health. 

Diagnosis. — The  peculiar  condition  of  the  mucous  membrane  of  the 
mouth,  the  pale,  fermenting,  and  strikingly  copious  stools,  the  wasting, 
and  the  history  of  residence  in  the  tropics,  suffice  to  establish  a  diagnosis 
of  sprue. 

Treatment. — The  most  efficient  treatment  for  this  disease  is 
undoubtedly  a  diet  exclusively  of  milk.  To  be  successful,  the  diet  should 
be  of  the  most  stringent  character,  and  persisted  in  for  many  weeks,  or 
even  months.  The  patient,  if  seriously  ill,  should  be  sent  to  bed  in  a  warm 
room  and  warmly  clothed.  At  first  the  daily  quantity  of  milk,  which  in 
cold  weather  must  be  slightly  warmed,  should  not  exceed  60  oz.  It 
should  be  taken  in  divided  quantities  at  intervals  of  an  hour ;  it  must  be 
sipped,  and  not  drunk.  If  the  treatment  is  to  prove  successful,  in  a  few 
days  the  motions  become  solid,  the  dyspeptic  distension  disappears,  and  the 
condition  of  the  mouth  rapidly  improves.  The  quantity  of  milk  may  now 
be  increased  gradually  until  six  or  eight  pints  are  taken  in  the  twenty-four 
hours  ;  this  must  be  continued  for  at  least  six  weeks.  If  all  signs  of  the 
disease  have  disappeared,  other  food  may  be  carefully  added;  at  first, 
raw  eggs,  thin  broths ;  then,  after  a  time,  chicken,  farinaceous  foods 
thoroughly  cooked  ;  and,  finally,  underdone  lean  of  meat.  When  bread  is 
introduced,  it  should  be  thoroughly  roasted  in  the  oven  till  dry,  yellowish 
brown,  and  crisp ;  biscuits  and  rusks  should  be  treated  in  a  similar  way. 
Starchy  foods  are  not  well  borne  in  this  disease,  the  smallest  quantity 
introduced  too  soon  often  causing  relapse.  If  during  convalescence  or  at 
any  future  time  the  tongue  become  sore,  or  dyspeptic  symptoms  reappear, 
or  diarrhoea  occur,  it  is  advisable  to  administer  some  mild  aperient  as 
castor-oil  or  Gregory's  powder,  on  the  first  indication  of  anything  going 
wrong.  Pending  their  action,  the  patient  should  starve.  A  pure  milk 
diet  must  again  be  had  recourse  to  for  two  or  three  days,  before  gradually 
returning  to  the  usual  food. 

Sometimes  the  milk  treatment  fails.  In  these  cases  peptonising  the 
milk  may  be  tried ;  or  a  diet  of  meat  juice,  or  one  of  underdone  or  scraped 
meat  had  recourse  to.  After  a  time  on  such  a  diet,  it  may  be  found  that 
milk  will  now  agree.  If  this  on  trial  should  prove  to  be  the  case,  milk 
may  be  added  permanently  to  the  dietary. 

Different  medicinal  remedies  have  been  used  for  this  disease ;  apparently 
little  reliance  can  be  placed  on  their  doing  any  permanent  good.  A  mild 
purgative  at  the  outset,  and  at  intervals,  is  advisable.  Opium  may  be  given 
with  care  if  the  diarrhoea  is  violent  at  any  time ;  it  may  be  combined  with 
chalk  or  bismuth.  Astringents  are  not  advisable.  At  times  peptonising 
substances  may  be  added  to  the  food  with  advantage ;   but,  on  the  whole, 


DENGUE  277 

the  treatment  must  be  principally  a  dietetic  and  hygienic  one.  When 
sprue  occurs  in  the  tropics,  or  even  when  it  is  threatened,  and  does  not  at 
once  yield  to  treatment,  the  patient  should,  if  possible,  return  to  Europe. 
During  the  winter  and  spring  months,  residence  in  the  south  of  Europe  or 
in  some  mild  climate  is  advisable. 

PATEICK  MANSON. 


DENGUE. 

An  infectious,  epidemic,  febrile  disease  confined  to  warm  climates  and 
characterised  by  a  definite  course,  an  initial  and  terminal  exanthem, 
severe  pains  in  the  joints  and  muscles,  and  an  insignificant  mortality. 

History  and  geographical  distribution. — The  earlist  accounts 
of  this  disease  date  from  1779,  and  refer  to  epidemics  in  Cairo  and  in 
Batavia.  Since  that  date  many  epidemics  have  been  recorded  as  spreading 
along  the  trade  routes  all  over  the  tropical  and  sub-tropical  world.  In 
Europe  epidemics  have  occurred  in  Spain,  Italy,  and  Greece.  In  1889, 
dengue  appeared  in  Syria,  Asia  Minor,  Greece,  and  the  neighbouring 
islands.  The  northern  limit  of  dengue  in  the  eastern  world  is  41'  1ST.,  in 
the  western  39'  N.  South  of  the  equator  it  probably  does  not  extend 
beyond  the  tropics.  Apparently  dengue  is  endemic  in  certain  countries — as 
Egypt,  the  Sandwich  Islands,  Tahiti,  the  east  and  west  coast  of  tropical 
Africa,  and  especially  in  the  West  India  Islands. 

Etiology. — The  specific  germ  is  unknown;  nevertheless,  local  epi- 
demics having  frequently  been  traced  to  imported  cases,  there  can  be 
little  doubt  about  the  infectious  nature  of  this  disease.  As  the  incubation 
period  is  very  short,  sometimes  not  exceeding  twenty-four  hours,  rarely 
more  than  two  days,  and  as  the  disease  is  generally  very  mild,  seldom  con- 
fining the  patient  to  the  house  for  more  than  a  few  days,  and  sometimes  not 
at  all,  and  as  the  patient's  body  continues  to  emit  the  infection  for  a  con- 
siderable time  after  recovery  and  while  he  is  mingling  with  the  general 
population,  the  rapid  spread  of  dengue  in  a  community — so  remarkable  a 
feature  in  this  disease — receives  a  ready  explanation.  High  atmospheric 
temperature  is  the  most  important  meteorological  condition  demanded; 
consequently  outside  the  tropics  dengue  occurs  only  during  the  summer ; 
cold  weather  at  once  puts  a  stop  to  .an  epidemic.  Dampness  or  dryness 
of  the  atmosphere,  the  character  of  the  soil,  and  elevation — apart  from 
their  effect  on  temperature — have  no  influence.    Ship  epidemics  often  occur. 

During  visitations  of  this  disease,  two-thirds,  or  three-fourths,  or  even  a 
larger  proportion  of  the  inhabitants  of  the  affected  district  are  attacked. 
Neither  age,  sex,  race,  nor  occupation  have  any  marked  influence  on  suscepti- 
bility. Neither  is  one  attack  invariably  protective  against  a  second ;  as  with 
influenza,  certain  individuals  appear  to  have  a  special  predisposition  and 
liability  to  recurrence.  The  lower  animals  also  are  said  to  suffer  from 
dengue. 

Morbid  anatomy  and  pathology. — In  the  few  recorded  fatal 
cases,  serous  effusions  in  joints,  pericarditis,  and  softening  of  the  myo- 
cardium have  been  noted.     The  spleen  is  not  enlarged. 

Symptoms. — As  a  rule,  prodromata  are  absent,  the  disease  usually 
commencing  with  remarkable  suddenness,  the  patient  being  well  one  hour 
and  acutely  ill  the  next.     Slight  shivering  is  quickly  followed  by  high 


278  GENERAL  DISEASES. 

fever,  severe  frontal  headache,  racking  pains  in  the  joints  and  muscles, 
a  general  sub-erythematous  flushing  of  the  skin — the  primary  eruption, 
bloated  face,  red  eyes,  photophobia,  quick  pulse  and  rapid  respiration.  In 
a  few  hours  the  temperature  may  reach  104°  or  over.  The  pains,  some- 
times excruciating,  which  constitute  so  characteristic  a  feature  of  dengue, 
affect  the  joints  both  large  and  small.  The  knees  are  a  common  seat ; 
both  they  and  other  joints  may  in  a  few  instances  be  red  and  swollen. 
The  muscles  are  also  attacked,  and  so  are  the  bones — hence  the  term 
"  breakbone  fever,"  one  of  the  many  names  applied  to  dengue.  These 
pains  come  and  go,  and  are  aggravated  by  movement.  They  may  persist 
during  and  for  a  long  time  after  convalescence. 

After  one,  two,  or  three  days,  the  initial  fever  subsides  either  by  crisis 
of  sweating,  of  diarrhoea,  of  epistaxis,  or  by  gradual  defervescence.  The 
patient  then,  apart  from  the  pains  which  in  greater  or  lesser  degree  may 
persist,  now  reverts  to  a  condition  of  comparative  comfort.  This  apyretic 
period,  of  from  one  to  three  days'  duration,  is  again  followed  by  a  further 
but  much  slighter  and  more  evanescent  rise  of  temperature  of,  perhaps,  a 
few  hours'  duration  only,  and  the  appearance  of  the  terminal  exanthem. 
This  eruption  is  usually  of  a  morbilliform  character,  appearing  successively 
on  hands,  arms,  face,  trunk,  legs,  and  feet.  Sometimes  it  tends  to  become 
confluent,  at  other  times  to  be  patchy  and  irregular.  After  a  few  days 
it  fades  in  the  order  of  its  appearance ;  to  be  followed  in  a  proportion  of 
cases,  eight  or  ten  days  later,  by  furfuraceous  desquamation,  occasionally 
accompanied  by  falling  of  the  hair  and  troublesome  itching  or  hyper- 
esthesia of  palms  and  soles.  Convalescence  is  seldom  delayed  beyond 
the  week;  but  it  may  be  further  protracted  by  such  complications  as 
boils,  neuralgia,  orchitis,  psychical  disturbance,  diarrhoea,  and  the  peculiar 
pains  alluded  to.  There  is  great  variety  in  the  severity  of  the  cases.  In 
some  epidemics  relapses  are  not  uncommon. 

Diagnosis  and  Prognosis. — The  exanthem,  and  the  absence  of 
profuse  sweating  during  the  fever,  together  with  the  nature  of  the  con- 
current epidemic,  suffice  to  differentiate  dengue  from  acute  rheumatism. 
Scarlet  fever,  besides  being  very  rare  in  the  tropics,  differs  from  dengue  in 
the  duration  of  the  fever,  in  the  severity  of  the  throat  symptoms,  in  the 
character  and  period  of  the  eruption,  and  in  the  nature  of  the  subsequent 
desquamation.  In  measles  the  catarrhal  symptoms  are  more  marked,  and 
there  are  no  severe  joint  pains  as  in  dengue.  In  influenza  the  pains  are 
absent  or  less  severe,  and  catarrhal  symptoms  are  common,  whilst  eruption 
is  rare.  Although  fever  and  suffering  may  be  great,  the  mortality  from ' 
dengue  is  almost  nil. 

Treatment. — Aperients  are  not  to  be  recommended,  as  the  move- 
ments consequent  on  attending  to  calls  to  stool  aggravate  the  pains. 
Fever  may  be  relieved  by  sponging,  ice  to  the  head,  cooling  drinks,  and 
two  or  three  doses  of  antipyrine  or  phenacetin — drugs  which  also  mitigate 
the  pains.  Diet  should  be  light  and  digestible.  The  patient  should  keep 
to  bed  till  after  the  disappearance  of  the  terminal  eruption.  During  con- 
valescence an  iron  and  quinine  tonic  is  advisable.  If  pains  persist, 
massage,  electricity,  iodide  of  potassium,  or  sulphur  baths,  will  be  found  of 
use.     A  change  of  air  is  always  advisable  after  severe  attacks. 

PATEICK  MAKSOK 


YELL  OW  FE  VER.  2  7  9 


YELLOW   FEVER 

An  acute,  communicable  tropical  disease,  with  a  remarkably  restricted 
geographical  distribution.  Clinically,  it  is  characterised  by  fever  having 
a  definite  course,  albuminuria,  icterus,  and  a  liability  to  haemorrhages 
— particularly  from  the  stomach.  Parenchymatous  fatty  degenerations  of 
liver  and  kidneys,  and  fatty  degeneration  of  the  heart  and  capillaries,  are 
found  post-mortem.  The  cause  is  believed  by  some  to  be  a  special 
bacterium. 

History  and  geographical  distribution.  —  Yellow  fever  was 
first  reported  in  1635.  Since  that  date  many  epidemics  have  occurred  in 
the  endemic  area  which,  roughly  speaking,  may  be  said  to  embrace  the 
West  India  Islands,  the  coasts  and  islands  of  the  Caribbean  Sea  and  Gulf 
of  Mexico,  the  coasts  of  Brazil  and  of  west  tropical  Africa.  The  disease 
has  occasionally  appeared  in  European  ports — in  England,  France,  Spain, 
and  Italy,  but,  with  the  exception  of  certain  epidemics  in  Spain  and 
Portugal,  it  has  never  obtained  a  firm  footing  in  Europe.  In  America,  the 
epidemics  outside  the  endemic  area  have  been  more  frequent  and  more 
severe.  Yellow  fever  has  occurred  along  the  North  American  seaboard, 
as  far  north  as  Halifax ;  along  the  Mississippi  Valley  as  high  as  St.  Louis ; 
in  South  America  as  far  south  as  Monte  Video ;  and  also  on  the  West 
Coast  on  both  sides  of  the  Equator.  An  important  fact  regarding  yellow 
fever  is  that  it  may  occur  on  shipboard  on  the  high  seas ;  only,  however, 
after  communication  with  an  infected  port  or  with  an  infected  vessel. 

Etiology. — The  organism  of  yellow  fever  is  believed  by  some  to  be 
B.  icteroides,  recently  discovered  by  Sanarelli ;  we  do  not  as  yet  know  with 
precision  the  medium  in  which  the  infection  enters  the  human  body. 
Apparently,  the  germ  is  not  water-borne. 

Unlike  the  exanthematous  fevers,  yellow  fever  is  not  directly  communi- 
cable from  sick  to  healthy.  It  spreads  only  by  a  process  of  place,  or  soil, 
or  ship  infection.  The  germ  certainly  passes  a  part  of  its  existence  out- 
side the  human  body  before  entering  it.  The  virus,  which  under 
certain  conditions  is  very  tenacious  of  life,  can  be  carried  by  man  either 
in  his  ships,  in  his  clothes,  or  about  his  body.  For  its  development  it 
requires  a  high  atmospheric  temperature,  being  most  active  if  the  heat  is 
combined  with  damp ;  hence  the  rainy  season  in  the  endemic  area  is  the 
most  favourable  for  epidemic  outbursts.  Copious  and  long-continued  rain, 
however,  sometimes  stops,  decided  fall  of  temperature  checks,  whilst  frost 
at  once  puts  an  end  to  an  epidemic.  The  germ  is  not  always  killed  out- 
right by  cold ;  it  may  remain  dormant  during  a  long  winter,  and,  reviving 
on  return  of  warm  weather,  again  cause  a  recrudescence  of  a  suspended 
epidemic. 

Large  and  densely-populated  seaports  are  the  favourite  haunt  of  yellow 
fever.  It  invades,  first  and  principally,  the  low-lying  slums  along 
harbours  and  docks ;  and  exhibits  the  same  preference  for  particular  dis- 
tricts and  houses  which  is  so  marked  a  feature  in  bubonic  plague.  Small 
inland  towns  and  villages  are  rarely  attacked.  Although  such  have  been 
recorded  (Cuzco,  1855-56),  epidemics  are  very  rare  in  towns  high  above 
the  sea  level.  Inside  the  endemic  area  yellow  fever  is  kept  alive  during 
the  non-epidemic  intervals  by  sporadic  cases,  which  every  now  and  again 
break  into  an  epidemic.  Outside  the  endemic  area  epidemics  are  always 
introduced  from  without,  and  can  generally  be  traced  to  some  individual 


2  So  GENERAL  DISEASES. 

or  ship  coming  from  a  place  where  the  disease  is  raging.  In  from  four 
to  eight  weeks  after  such  an  importation,  a  few  scattered  cases  having 
occurred  in  the  meantime,  it  bursts  out  in  epidemic  force,  and  continues 
for  a  period  of  weeks,  or  months,  or  even  of  years,  varying  in  intensity 
from  time  to  time  in  harmony  with  meteorological  and  other  circum- 
stances. 

Liability  to  yellow  fever  is  singularly  influenced  by  race  and  by  dura- 
tion of  residence  in  the  endemic  area.  The  negro  is  very  little  liable,  and, 
when  attacked,  the  disease  in  him  is  much  milder,  as  a  rule,  than  in  the 
European ;  the  latter  is  likewise  much  more  susceptible.  Mongolians  and 
mulattos  occupy  an  intermediate  position  in  these  respects.  Liability  to 
yellow  fever  diminishes  in  a  most  marked  manner  with  length  of  resid- 
ence in  the  endemic  area ;  this  acquired  immunity  is  partially  lost  when  the 
endemic  area  is  quitted  temporarily.  One  attack  of  yellow  fever  is  almost 
absolutely  protective  against  a  second.  Sex  has  no  marked  influence  on 
susceptibility.  Childhood  and  old  age  are  rarely  attacked — 10  to  30  being 
the  age  of  greatest  liability.  The  strong  are  more  liable  to  attack  than 
the  weak  and  anaemic. 

Morbid  anatomy  and  pathology.  —  Besides  the  icterus  and 
other  lesions  already  mentioned,  the  skin  may  be  the  seat  of  petechia?, 
and  the  muscles  of  more  extensive  extravasations  of  blood.  Punctate 
haemorrhages  occur  in  most  serous  and  mucous  membranes.  All  tissues 
and  fluids  have  a  marked  yellow  colour.  The  heart  frequently,  though  not 
invariably,  is  pale,  dilated,  and  degenerated.  The  blood  is  dark  and  fluid. 
The  capillaries  are  the  subject  of  a  fatty  degeneration ;  hence  one  cause 
at  least  for  the  hsemorrhagic  tendency.  Black,  grumous,  acid,  altered 
blood  may  be  present  in  large  quantities  in  the  stomach  and  intestine. 
There  may  be  hypersemic  patches,  or  even  erosions,  in  the  intestinal 
mucosa.  In  the  early  stages  of  the  disease  the  liver  is  hypersemic ;  but 
if  death  occur  later  this  organ  is  usually  anaemic,  pale,  and  small,  the 
liver  cells  containing  a  phenomenal  abundance  of  fat,  besides  granules  of  a 
yellow  pigment.  The  spleen  is  not  affected.  The  kidneys  are  hypersemic, 
and  show  cloudy  swelling,  with  fatty  degeneration  and  desquamation  of 
the  renal  epithelium.  The  specific  bacterium,  according  to  Sanarelli,  is 
found  more  especially  in  the  liver. 

Symptoms. — Yellow  fever,  although  sometimes  preceded  by  a  day 
or  two  of  malaise,  generally  sets  in  suddenly,  often  during  the  night,  with 
sharp  rigor  or  with  alternating  heats  and  chills.  Eestlessness,  prostra- 
tion, violent  frontal  and  orbital  headache,  and  pains  in  the  back,  loins,  and 
legs  are  particularly  urgent.  The  thermometer  rapidly  mounts  to  103°  or 
104°,  or  even  higher.  The  pulse  is  at  first  full  and  bounding,  and  the 
respirations  rapid  and  shallow.  The  skin  may  be  perspiring,  or  it  may  be 
hot  and  dry ;  occasionally  erythematous  eruptions,  urticaria,  sudamina,  or 
pustules  are  noticed.  The  face  is  red  and  swollen ;  the  eyes,  injected  and 
watery,  shun  the  light.  The  tongue,  at  first  moist  and  swollen,  quickly 
becomes  small,  dry,  and  brown ;  the  fauces  and  gums  are  congested.  Thirst 
is  urgent ;  anorexia  complete.  The  epigastrium  is  tender,  and  there  may  be 
vomiting.  The  urine  is  scanty,  acid,  and,  from  the  first,  may  contain  a 
trace  of  albumin.  This,  the  "  primary  fever,"  continues  in  ordinary  cases 
from  three  to  five  days,  occasionally  as  long  as  seven.  During  this  stage 
the  patient  may  die  of  suddenly  developed  hyperpyrexia.  As  a  rule,  how- 
ever, the  fever  abates,  and  the  patient  enters  on  what  is  known  as  "  the 
period  of  calm,"  a  stage  of  almost  complete  apyrexia  and  of  comparative 


YELL  O  W  FE  FEE.  2  8 1 

comfort,  but  also  one  of  considerable  prostration,  in  which  the  pulse  is 
generally  abnormally  slow.  Albuminuria  is  now  almost  invariably  present. 
This  stage  may  last  two  or  three  days,  when  the  patient  passes  either  into 
rapid  convalescence,  or  into  the  third  stage. 

If  the  latter  be  the  case,  there  is  a  return  of  fever,  usually  of  a  remit- 
tent character,  in  which  the  temperature  ranges  somewhat  lower  than 
during  the  primary  fever;  occasionally  the  rise  of  temperature  may 
amount  to  a  degree  or  two  only.  Delirium,  sometimes  of  a  furious  char- 
acter, more  often  low  and  muttering,  supervenes ;  or,  the  mind  remaining 
clear,  there  may  be  a  complete  apathy  and  prostration.  The  prominent 
symptom  is  the  intense  collapse.  The  features  become  shrunken ;  the 
pulse  slow,  small,  and  flagging.  Epigastric  tenderness  and  burning  return, 
and  vomiting  may  once  more  set  in.  The  vomited  matters,  at  first  watery, 
gradually  from  increasing  admixture  of  blood  become  dark  and  grumous 
like  coffee-grounds ;  this  is  the  well-known  and  justly  dreaded  "  black 
vomit,"  an  almost  fatal  symptom.  Diarrhoea  of  a  similar  character  may 
also  come  on.  Occasionally  pure  blood  is  passed  in  the  stool  or  is  vomited. 
There  is  now  anuria  and  a  state  of  profound  algidity,  as  in  cholera.  Con- 
sciousness may  be  maintained  to  the  end ;  generally  the  patient  falls  into 
a  stupor  and  such  symptoms  as  singultus,  Cheyne-Stokes'  respiration, 
fibrillar  twitching  of  muscles,  or  convulsions,  precede  death.  Eecovery 
from  this  condition  of  collapse  is  a  rare  event ;  it  does  occur,  however,  at 
times,  the  patient  breaking  out  into  a  profuse  perspiration  and  slowly 
entering  on  a  protracted  convalescence. 

During  the  third  stage  of  yellow  fever,  haemorrhage  may  take  place, 
not  only  from  stomach  and  bowel,  but  also  from  nose,  mouth,  ears,  eyes, 
lungs,  kidneys,  and  other  organs.  If  pregnancy  be  present,  miscarriage  is 
almost  invariable. 

The  yellowness  of  the  skin,  from  which  the  disease  receives  its  name, 
does  not  always  show  itself  during  life,  particularly  if  death  has  occurred 
early;  but  even  in  these  cases  it  is  invariably  developed  after  death. 
Although  it  usually  commences  to  appear  towards  the  end  of  the  primary 
fever,  it  may  not  be  present  until  later — during  the  period  of  calm,  or  in  the 
stage  of  collapse.  The  scleras,  the  skin  of  the  face,  neck,  and  upper  part  of 
the  trunk  gradually  acquire  a  pale  yellow  tinge,  which  steadily  deepens  to 
a  deep  orange  colour,  or  even  to  a  dark  mahogany-brown.  Notwithstanding 
the  colour  of  the  skin,  there  may  be  no  bile  in  the  urine,  and  the  f feces 
may  be  normally  coloured;  the  icterns,  therefore,  which  may  continue 
to  increase,  even  after  death,  is  hsematogenous.  Sometimes  the  bodies  of 
yellow  fever  patients,  even  at  an  early  stage  of  the  disease,  emit  a  peculiar 
and  characteristic  fishy  odour. 

Complications  of  various  kinds — such  as  parotitis,  boils,  diarrhoea,  and  so 
forth — may  delay  convalescence.  Eelapse  may  occur  and  prove  extremely 
dangerous. 

The  severity  of  yellow  fever  varies  within  wide  limits.  Abortive 
attacks,  in  which  there  is  only  an  evanescent  fever  unattended  by  icterus 
and  terminating  in  a  crisis  of  diaphoresis,  are  not  uncommon.  Sometimes 
patients  continue  at  their  work  during  one  of  these  mild  attacks.  Such 
cases  may  suddenly  develop  black  vomit,  with  symptoms  of  collapse,  and 
die.  On  the  other  hand,  cases  may  be  fulminating  in  character  from  the 
outset,  and  rapidly  terminate  in  death  on  the  first  or  second  day. 

The  mortality  from  yellow  fever  varies  very  much  in  different  races,  in 
different  epidemics,  in  different  periods  and  localities  of  the  same  epidemic, 


282  GENERAL  DISEASES. 

and  also  according  to  degrees  of  acclimatisation.     It  ranges  anywhere  from 
5  per  cent,  to  75  per  cent,  of  those  attacked. 

Diagnosis. — Mild  cases  of  yellow  fever  may  be  hard  to  recognise. 
It  is  not  always  easy  to  say  whether  a  given  case  of  fever  with  icterus  is 
yellow  fever,  or  whether  it  is  severe  bilious  remittent,  or  malarial  hsemo- 
globinuric  fever.  Considerations  regarding  the  nature  of  the  prevailing 
epidemic,  and  the  result  of  a  microscopical  examination  of  the  blood,  par- 
ticularly the  latter,  are  the  most  trustworthy  guides.  The  occurrence  of 
a  period  of  calm,  with  slowness  of  the  pulse,  followed  by  rapid  rise  of 
temperature,  together  with  albuminuria,  point  to  yellow  fever;  splenic 
tumour  and  hepatic  engorgement,  to  malarial  disease.  Flushed,  swollen  face ; 
congested,  sunken  eyes ;  severe  headache,  and  photophobia,  suggest  yellow 
fever.     In  all  cases  of  doubt  the  blood  must  be  examined  microscopically. 

Prognosis. — Prognosis  is  always  doubtful,  even  in  apparently  mild 
cases.  It  is  better  for  women  and  children  than  for  men ;  for  the  spare, 
the  anaemic,  and  the  temperate,  than  for  the  stout,  robust,  and  intemperate ; 
worst  of  all  for  the  newcomer.  Danger  increases  in  proportion  to  the  rise 
of  body  temperature.  The  disease  is  rarely  fatal  if  the  temperature  does 
not  exceed  103o-5 ;  always  fatal  when  it  passes  106°.  If  the  primary 
fever  continue  beyond  the  third  or  fourth  day,  it  is  a  bad  sign.  A 
scanty  secretion  of  urine  and  copious  albuminuria  are  also  bad.  Severe 
vomiting,  early  appearance  of  icterus,  black  vomit,  and  severe  nervous 
symptoms,  are  all  of  them  of  grave  import. 

Treatment. — Prophylaxis,  whether  on  shore  or  on  shipboard,  should 
include  careful  sanitation  and  a  quarantine  based  on  a  five  days'  incubation 
period.  During  cold  weather,  yellow  fever  need  not  be  apprehended.  On 
the  appearance  of  the  disease  in  a  town,  the  most  perfect  sanitation  and 
the  most  rigid  isolation  and  disinfection  must  be  enforced. 

There  is  no  specific  for  yellow  fever.  At  the  outset  a  full  dose  of  castor- 
oil  or  of  calomel  should  be  given;  subsequently,  aperients  may  be  used 
only  with  the  greatest  circumspection.  Frequently  repeated  hot  foot- 
baths with  mustard,  or  hot  baths,  are  much  used  during  the  early  stages, 
and  are  said  to  be  beneficial.  Cold  applications  to  the  head,  and  cold 
sponging  of  the  body,  and,  in  suitable  cases,  the  cold  bath,  are  the  best 
antipyretics.  Restlessness  and  insomnia  may  be  treated  with  antipyrine 
or  phenacetin  in  moderate  doses ;  morphine  is  dangerous.  Dry-cupping 
relieves  loin-ache ;  sinapisms  lessen  epigastric  distress ;  ice  and  small 
doses  of  cocaine  may  mitigate  vomiting.  Some  prescribe  astringents,  such 
as  perchloride  of  iron,  for  haemorrhages.  During  collapse,  alcoholic  stimu- 
lants are  necessary.  Sternberg  claims  brilliant  results  from  the  systematic 
use  of  the  following  mixture: — Bicarbonate  of  soda,  150  grs. ;  bichloride 
of  mercury,  \  gr. ;  water,  1  pint.  Dose,  three  tablespoonfuls,  given  cold, 
every  hour. 

The  feeding  during  yellow  fever  must  be  carefully  attended  to.  No 
food  should  be  given  during  the  primary  fever ;  later,  an  ounce  or  two  of 
iced  milk,  or  chicken-broth,  may  be  given  every  three  or  four  hours,  or  at 
shorter  intervals  in  smaller  quantities.  If  this  provoke  vomiting,  feeding 
by  the  mouth  must  be  suspended  and  nutrient  enemata  administered 
instead.  During  convalescence  the  diet  for  some  days  must  be  restricted 
to  fluid  nourishment ;  subsequently,  only  the  most  simple  and  digestible 
solids  are  permissible.  Indiscretion  in  the  matter  of  food  is  prone  to  cause 
relapse — a  most  dangerous  occurrence. 

PATRICK  MAXSOX. 


BERIBERI.  283 


BEEIBEEI. 


A  specific  endemo-epidemic,  multiple  peripheral  neuritis,  occurring 
especially  in  warm  climates.  It  is  distinguishable  from  other  forms  of 
polyneuritis  by  marked  tendency  to  implication  of  the  pneumogastric, 
phrenic,  and  vasomotor  nerves,  by  liability  to  dropsy,  and  by  the  frequency 
of  sudden  death  from  dilatation  of  the  heart. 

History  and  geographical  distribution. — Our  modern  know- 
ledge of  beriberi  begins  with  the  writings  of  Bontius,  who  practised  in  the 
Netherlands  Indies  about  the  middle  of  the  seventeenth  century.  Malcolm- 
son  wrote  an  excellent  clinical  account  of  the  disease,  as  it  occurs  in  British 
India,  in  1835.  Its  recent  recognition  as  a  form  of  peripheral  neuritis  we 
owe  particularly  to  Scheube,  Balz,  Pekelharing,  Winkler,  and  others. 

Beriberi  occurs  in  many  parts  of  the  tropical  and  subtropical  world. 
Frequently  met  with  in  the  tropical  and  subtropical  regions  of  Asia,  Africa, 
and  America,  it  seems  to  be  especially  common  in  Brazil,  the  Eastern 
Archipelago,  and  Japan.  Recently  it  has  been  seen  among  Chinese  and 
aborigines  in  Australia.  Although  occurring  principally  in  low-lying, 
damp,  coast  and  river  lands,  it  is  not  unknown  in  inland  districts.  The  recent 
epidemics  of  polyneuritis  in  the  Pdchmond  Asylum,  Dublin,  in  Erance,  and 
in  at  least  two  lunatic  asylums  in  the  United  States  of  America,  appear 
to  be  of  this  or  of  a  closely  allied  nature.  Unlike  malaria,  it  is  as  common 
in  towns  as  it  is  in  the  country ;  and,  also  unlike  malaria,  it  frequently 
breaks  out  among  the  crews,  especially  native  crews,  of  ships  trading  in 
the  tropics.  Among  these  crews  it  is  occasionally  seen  in  our  large 
seaports. 

Etiology. — There  have  been  many  speculations  as  to  the  nature  and 
cause  of  beriberi.  With  English  writers  there  was  a  tendency  at  one  time 
to  regard  it  as  a  manifestation  of  scorbutus,  of  malaria,  of  rheumatism,  or  of 
anaemia.  Some  have  attributed  it  to  the  use  of  diseased  rice,  others  to  a 
diet  deficient  in  nitrogen.  On  examination,  however,  none  of  these  views 
hold.  A  study  of  the  epidemics  shows  unmistakably  that  beriberi  has  all 
the  attributes  of  a  specific  and  germ-caused  disease.  Amongst  other 
evidences  which  could  be  cited  in  support  of  this  view  there  are  the  facts 
that  it  can  be  transported  by  human  intercourse  from  one  place  to  another, 
and  that  it  can  be  acquired  only  in  certain  districts,  often  only  in  limited 
localities  in  these  districts.  Were  it  dependent  on  causes  such  as  those 
first  mentioned,  this  liability  to  transportation,  and  these  geographical 
limitations,  would  not  obtain.  Direct  contagion  has  not  been  established, 
but  there  are  on  record  several  well-authenticated  instances  of  the  intro- 
duction of  beriberi  into  a  virgin  country,  and  the  subsequent  spread  of  the 
disease  there. 

Although  the  germ  has  not  been  discovered,  notwithstanding  numerous 
efforts  made  in  this  direction,  we  know  something  about  the  conditions  in 
which  it  nourishes.  The  principal  of  these  are  warmth,  overcrowding,  a 
high  degree  of  atmospheric  moisture,  and  damp.  In  the  tropics  it  prevails 
mostly  during  the  rainy  season ;  outside  the  tropics  it  occurs  during  the 
summer  and  autumn. 

As  regards  distribution  in  the  endemic  areas,  it  is  found  that  the 
disease  is  limited  to  certain  houses,  often  to  certain  parts  of  these  houses, 
particularly,  though  not  necessarily,  the  ground-floor.  It  is  prone  to 
appear  in  prisons,  in  barracks,  in  schools,  in  convents,  in  mining  camps,  in 


2S4  GENERAL  DISEASES. 

coolie  lines  on  plantations,  and  in  other  places  where  large  numbers  of 
individuals  live  crowded  together  in  unhygienic  conditions.  In  ships  it  is 
most  liable  to  occur  among  the  native  crews,  when  bad  weather,  or  cold 
weather,  cause  the  men  to  huddle  together  for  warmth  in  dark,  damp,  and 
ill- ventilated  forecastles.  Once  introduced  into  a  house,  school,  ship,  etc., 
it  tends  to  become  endemic,  recurring  over  and  over  again,  and  year  after 
year,  especially  in  hot  weather,  or  in  the  presence  of  unusual  overcrowd- 
ing and  defective  hygiene. 

It  is  difficult  to  say  what,  as  regards  the  human  body,  is  the  exact 
location  of  the  germ  or  how  it  operates.  Like  the  germ  of  malaria,  it  can 
live  and  multiply  outside  the  human  body ;  but  whether  it  does  or  does  not 
enter  the  body  is  uncertain.  Some  think  that  it  does  enter  the  body ;  I 
myself  favour  the  idea  that,  residing  in  the  soil,  it  manufactures  there  a 
toxine  which,  on  being  inhaled  or  swallowed,  produces  the  characteristic 
neuritis. 

Attacks  of  beriberi  are  apt  to  be  provoked,  after  longer  or  shorter 
residence  in  the  endemic  area,  by  chills,  catarrhs,  shocks,  over-fatigue, 
dysentery,  unphysiological  dietary,  hardships,  surgical  operations,  and  so 
forth. 

It  affects  all  conditions  of  life,  rich  and  poor  alike  ;  if  anything,  it  has 
a  predilection  for  the  robust  and  the  new-comer.  It  tends  to  recur  in  the 
same  individual ;  in  Japan,  cases  have  been  noted  which  have  recurred 
every  summer  during  a  long  series  of  years.  A  certain  degree  of  immunity 
by  acclimatisation  may  be  acquired.  Apparently  the  Malay  rarely  con- 
tracts beriberi  in  his  own  home,  but  the  Chinese  immigrant  is  very  sub- 
ject to  it  in  the  Malay  country;  and,  it  is  said,  if  a  Malay,  immune 
to  beriberi  in  his  native  place,  migrate  to  some  other  beriberic  spot, 
he  may  there  acquire  the  disease. 

All  ages,  excepting  the  very  youngest,  are  liable ;  it  is  most  prevalent 
between  20  and  35.  Children  under  8  years  of  age,  and  probably  the 
very  aged,  are  rarely  affected.  Although  women  are  not  so  frequently 
attacked  as  men,  pregnant  and  puerperal  women  are  particularly  subject  to 
beriberi.     Infants  suckled  by  beriberic  mothers  acquire  the  disease. 

Morbid  anatomy  and  pathology.  —  The  essential  lesions  in 
beriberi  are  those  of  a  peripheral  neuritis,  with  secondary  degeneration  and 
atrophy  of  the  implicated  nerves  and  muscles.  The  most  important  lesion, 
as  affecting  life,  is  that  involving  the  pneumogastric  nerve  and  its  cardiac 
branches.  To  this  are  attributable  the  various  cardiac  symptoms,  includ- 
ing the  too  often  fatal  dilatation  of  the  right  side  of  the  heart.  The  oedenia 
of  the  connective  tissue,  the  occasional  oedema  of  the  lungs,  and  the 
serous  effusions  into  pleurae  and  pericardium,  probably  depend  on  similar 
implication  of  the  vasomotor  system.  The  central  nervous  system  is  not 
involved. 

Symptoms. — Sometimes  a  trifling  and  barely  noticeable  affection, 
beriberi,  on  the  other  hand,  is  not  unfrequently  a  disease  of  the  utmost 
gravity.     Between  these  extremes  there  is  infinite  gradation. 

Prodromata  in  the  shape  of  languor,  pains,  and  weakness  in  the  legs, 
transient  numbness  over  the  tibiae,  palpitations,  cramp,  and  fever  are 
occasionally,  but  by  no  means  invariably  present.  Catarrhal  symptoms 
and  diarrhoea  are  sometimes  noted.  With  or  without  these,  rapidly  or 
more  slowly,  the  characteristic  symptoms  are  evolved.  For  convenience, 
the  various  clinical  types  may  be  classified  as — (1)  Larval,  (2)  atrophic, 
(3)  hydropic,  (4)  mixed,  and  (5)  malignant. 


BERIBERI.  285 

Larval  beriberi. — Patients  complain  of  feelings  of  weakness  or  pains 
in  the  legs,  numbness  of  the  skin  of  the  pretibial  area  and  occasionally 
of  the  finger-tips,  possibly  of  palpitation  and  of  a  certain  amount  of 
breathlessness  ;  but  they  are  able  to  be  about,  can  walk  with  more  or  less 
difficulty,  and  in  other  respects  feel  and  look  well.  On  examining  the  legs, 
a  certain  amount  of  dulling  of  common  sensation  over  the  tibire,  dorsa  of 
the  feet,  perhaps  of  the  thighs,  fingers,  and  forearms,  can  be  made  out. 
Firm  pressure  against  the  bone  shows  that  the  calf  muscles  are  distinctly 
hypersensitive.  Knee-jerks  after  a  time  are  usually  in  abeyance.  Slight 
oedema  over  the  tibiae  and  ankles  can  generally  be  detected.  Irritability 
of  the  heart,  and  perhaps  a  cardiac  (usually  systolic)  bruit,  coming  and 
going,  are  generally  to  be  made  out.  The  case  may  linger  on  in  this 
condition  for  weeks  or  months,  a  little  better  one  day,  a  little  worse  the 
next,  until  finally  symptoms  disappear,  or,  on  the  other  hand,  slowly  or 
more  rapidly  develop  into  graver  forms  of  the  disease. 

Atrophic  beriberi.  —  In  this  the  muscles,  particularly  and  in- 
variably the  muscles  of  the  legs,  and  often  of  the  thighs,  hands,  and 
forearms,  and,  in  rare  cases,  of  the  trunk,  rapidly  undergo  marked  wasting. 
When  the  disease  is  fully  developed,  and  is  present  in  a  high  degree,  the 
patient  appears  like  a  skeleton  covered  with  skin.  There  is  generally  some 
oedema  at  an  early  stage,  but  this  is  always  inconsiderable,  and  may  disap- 
pear. Compression  of  the  affected  muscles  causes  considerable,  often 
exquisite  suffering  ;  the  knee-jerk  and  other  deep  reflexes,  and,  in  extreme 
cases,  the  superficial  reflexes,  are  abolished.  Sensation  in  the  skin  over 
the  atrophied  muscles  is  diminished — sometimes,  especially  over  the  shins, 
almost  abolished.  The  power  of  movement  is  impaired  in  proportion  to 
the  degree  of  muscular  atrophy,  and  a  certain  amount  of  ataxia,  in  addition 
to  mere  muscular  weakness,  may  be  present.  Walking  may  be  impossible. 
The  reaction  of  degeneration  is  invariably  present  in  the  affected  muscles 
in  all  types  of  beriberi.  Sometimes  nearly  all  the  voluntary  muscles,  with 
the  exception  of  those  of  the  face,  eyes,  and  those  subserving  deglutition 
and  respiration,  are  completely  inoperative,  and  the  patient  lies  on  his  bed 
absolutely  unable  to  move.  In  these  cases  the  functions  of  organic  life 
may  not  be  seriously  interfered  with ;  there  is  no  fever,  and,  unless  the 
muscles  are  roughly  handled,  little  pain,  although  cramps  and  various 
parsesthesise  may  occur  from  time  to  time.  In  all  the  markedly  atrophic 
cases  there  is  evidence  in  palpitation,  breathlessness,  cardiac  bruits,  and 
often  in  increased  precordial  dulness,  in  pulsating  cervical  vessels  and 
epigastrium,  of  implication  of  the  cardiac  branches  of  the  vagus  and  conse- 
quent dilatation  of  the  heart.  Sometimes  the  phrenic  is  also  involved,  and 
then  there  may  be  paresis  of  the  diaphragm.  Similarly,  implication  of  the 
recurrent  laryngeal  nerve  may  give  rise  to  aphonia  from  laryngeal  paresis. 
The  intercostal  and  abdominal  muscles  may  also  be  affected.  The 
sphincters  are  never  attacked,  and  there  is  no  tendency  to  bed-sores  or 
other  trophic  affections  of  the  integument 

In  all  degrees  of  atrophic  beriberi,  and  at  any  time  in  its  course,  the 
patient  may  die  suddenly  from  syncope,  or  more  frequently  from  a  rapidly- 
developed  dilatation  of  the  right  heart.'  In  favourable  cases — fortunately 
the  majority — sensation  and  muscular  power,  after  weeks  or  months, 
gradually  return,  and  the  muscles  are  entirely  or  partially  slowly  re- 
habilitated. Occasionally  some  deformity,  as  talipes  equinus,  may  result 
from  permanent  atrophy  or  from  permanent  shortening  of  muscles. 

Hydropic  bariberi. — Like  the  atrophic  form,  hydropic  beriberi,  with 


286  GENERAL  DISEASES. 

or  without  prodromata,  may  set  in  slowly  or  suddenly,  be  attended  with 
urgent  symptoms  depending  on  cardiac  or  respiratory  implication,  or  it 
may  run  a  mild  course  without  these  fully  developing.  There  is  extensive 
general  dropsy,  with  partial,  sometimes  almost  complete,  suppression  of 
urine.  Palpitation  of  the  heart  and  cardiac  oppression  are  usually  pro- 
minent symptoms.  Anaesthesia  and  muscular  paresis  of  the  legs  or  of  the 
hands  and  arms  may  not  be  present ;  they  are  rarely  so  marked  as  in  the 
atrophic  type.  There  is  a  great  tendency  to  serous  effusion,  especially  into 
the  pleurae  and  pericardium,  to  the  development  of  dilatation  of  the  heart, 
to  cardiac  bruits,  and  to  oedema  of  the  lungs.  After  a  variable  time 
of  weeks  or  months,  profuse  diuresis  may  set  in ;  the  bloated  body 
then  rapidly  diminishes  in  bulk,  the  wasting  of  the  limbs  from  atrophy  of 
the  muscles,  if  such  has  occurred,  becoming  now  very  apparent. 

Mixed  beriberi. — Atrophic  beriberi  may  assume  hydropic,  and  hydropic 
beriberi  may  assume  atrophic,  characters.  Some  cases  from  the  outset  are 
of  a  mixed  nature,  a  fair  amount  of  general  or  more  local  oedema  con- 
curring with  well-marked  muscular  paresis. 

Malignant  beriberi. — A  case  from  the  outset  may  exhibit  indications 
of  grave  cardiac  and  respiratory  implication,  palpitations  and  breathlessness 
constituting  the  most  urgent  symptoms  ;  or  such  may  supervene  in  the 
course  of  the  ordinary  atrophic,  hydropic,  or  mixed  types,  particularly  in 
the  case  of  the  two  latter.  In  these  very  dangerous  cases,  attacks  of  breath- 
lessness, palpitations,  feelings  of  substernal  and  epigastric  distress — often  of 
a  most  acute  and  painful  character — and  restlessness  recur  at  varying 
intervals.  There  is  marked  tendency  to  dilatation  of  the  right  heart  as  well 
as  to  pericardial  and  pleural  effusion,  sometimes  to  oedema  of  the  lungs. 
At  any  time  exacerbation  of  these  conditions  may  set  in,  and  the  patient 
be  suddenly  seized  with  extreme  dyspnoea,  which  very  likely  proves  fatal 
in  a  short  time,  sometimes  in  a  few  minutes  even.  In  bad  epidemics 
such  cases  are  common.  Death  has  been  known  to  occur  within  a  few 
hours  of  the  commencement  of  the  disease. 

Diagnosis. — Epidemic  peripheral  neuritis  in  warm  climates  is  almost 
invariably  beriberi.  Pretibial  oedema;  muscular  atrophy;  tenderness  of 
the  muscles;  palpitation  and  cardiac  bruits;  analgesia  of  the  shins; 
absence  (not  invariable)  of  knee-jerks ;  non-implication  of  the  ocular, 
facial,  and  pharyngeal  muscles;  absence  of  fever  in  the  established 
disease,  suffice,  as  a  rule,  to  guide  to  a  correct  diagnosis.  A  not  infrequent 
cause  of  confusion  is  the  occurrence  of  peripheral  neuritis  in  the  in- 
temperate within  the  endemic  beriberi  area ;  in  such  a  case  the  history 
will  be  of  great  service.  A  very  little  attention  to  the  symptoms  and 
history  will  prevent  confusion  with  such  diseases  as  locomotor  ataxia, 
progressive  muscular  atrophy,  heart  disease,  nephritis,  trichinosis,  etc. 

Prognosis. — The  mortality  of  beriberi  ranges  in  different  epidemics 
from  2J  per  cent,  to  50  or  even  70  per  cent,  of  those  attacked,  varying 
very  much  according  to  the  type  of  epidemic  and  the  treatment  adopted. 
Hydropic  cases  with  great  diminution  of  urine  are,  as  a  rule,  more  serious 
than  atrophic  cases,  those  with  palpitation  and  other  urgent  signs  of 
pneumogastric  implication  than  the  simple  atrophic  cases.  Vomiting  is 
always  a  grave  symptom,  indicating  as  it  does  advancing  implication  of  the 
pneumogastric  nerves.  Signs  of  cardiac  dilatation — as  loud  bruits,  enlarged 
praecordial  dulness,  throbbing  in  the  epigastrium  and  neck — are  ominous. 
It  is  very  unsafe  to  venture  on  a  prognosis  in  beriberi,  for,  even  in  appar- 
ently mild  cases,  sudden  implication  of  the  pneumogastric  may  lead  to  a 


YAWS.  287 

rapidly  fatal  issue.  The  clanger  is  especially  great  when  the  patient  is 
obliged  to  remain  on  the  spot  in  which  the  disease  was  contracted.  On 
the  whole,  although,  as  stated,  epidemics  differ  in  fatality,  beriberi  is  a  more 
serious  disease  in  the  tropics  than  in  higher  latitudes. 

Treatment. — The  patient  must  at  once  be  removed  from  the  endemic 
area.  His  food  should  be  light  and  nutritious  ;  fresh  vegetables,  milk,  eggs, 
fish,  and  meat  being  substituted  for  the  rice  on  which  he  has  probably 
been  mainly  subsisting.  Experience  has  shown  that  bulky  food,  such  as 
rice,  is  injurious  in  beriberi.  If  seriously  ill,  the  patient  ought  to  be  kept 
in  bed  ;  if  not  very  ill,  he  ought  to  spend  most  of  his  time  in  the  open  air. 
Sleeping-quarters  should  be  well  off  the  ground,  dry,  light,  and  airy.  A 
saline  aperient  should  be  administered  frequently  during  the  more  active 
stages  of  the  disease  ;  if  the  heart  is  feeble,  irritable,  and  dilated,  digitalis 
should  be  given  regularly.  During  a  paroxysm  of  dyspnoea,  nitrite  of 
amyl  or  nitroglycerin  must  be  freely  exhibited  in  full  and  frequently- 
repeated  doses.  There  must  be  no  delay  in  administering  this  remedy ; 
nurses  should  be  instructed  in  its  use  and  informed  of  the  indications  for 
its  prompt  employment.  If  it  fail  to  give  immediate  relief,  the  patient 
must  be  bled  from  the  arm  or  external  jugular ;  10  oz.  of  blood  will  prob- 
ably suffice,  but  the  bleeding  may  have  to  be  repeated  subsequently. 
The  over-distended  right  heart  must  be  relieved  at  all  risks.  When  the 
muscles  are  no  longer  tender,  faradisation,  massage,  strychnine,  and 
general  tonics  with  change  of  air,  especially  a  sea  voyage,  are  of  great 
service. 

Disinfection,  prevention  of  overcrowding,  scrupulous  cleanliness  and 
dryness,  sleeping  off  the  ground  in  well-ventilated  rooms,  and,  when 
feasible,  the  temporary  abandonment  of  the  affected  quarters,  are  indicated 
in  the  presence  of  an  epidemic.  The  food  should  be  good  and  sufficient, 
and  the  clothing  warm. 

PATEICK  MANSOK 


YAWS. 

Syn.,  Frambcesia. 


A  contagious  disease  of  the  tropics,  characterised  by  a  short  but  some- 
what indefinite  incubation  period ;  a  prodromal  fever,  accompanied  by 
rheumatic-like  pains ;  and  a  fungating,  encrusting,  granulomatous  skin 
eruption.  It  runs  a  chronic  course  of  several  months'  or  years'  duration, 
and,  to  a  certain  extent,  is  amenable  to  mercury  and  the  iodides.  One 
attack  is,  as  a  rule,  protective  against  a  recurrence. 

History  and  geographical  distribution. — There  has  been 
some  controversy  as  to  the  possible  identity  of  this  disease  with  the 
"sibbens"  of  Scotland  and  the  "button  scurvy"  of  Ireland.  Probably 
they  were  not  the  same.  At  the  present  day  yaws  is  found  only  within 
the  tropics,  and  not  everywhere  there.  It  is  particularly  prevalent  in  the 
West  Indies  among  the  negroes,  in  tropical  Africa,  in  Ceylon  ("  parangi "), 
in  Fiji  ("  coko "),  and  the  islands  of  the  South  Pacific ;  in  Java,  Burma, 
Assam,  and  probably  elsewhere.  In  many  of  these  places  every  child 
passes  through  an  attack ;  in  Fiji  it  is  systematically  inoculated  (Daniels). 

Etiology. — Although  the  germ  has  as  yet  not  been  recognised,  there 
can  be  no  doubt  that  yaws  is  a  germ  disease.     Micro-organisms — cocci — 


288  GENERAL  DISEASES. 

have  been  found  in  the  lesions,  but  proof  is  wanting  that  these  constitute 
the  specific  germ.  Under  ordinary  circumstances,  the  disease  is  acquired 
by  direct  contact  with  a  yaws  sore,  or  the  virus  is  accidentally  applied  by 
fingers,  insects,  dirty  clothes,  or  otherwise.  A  breach  of  surface  is 
necessary  for  infection.  All  races  and  all  ages  are  susceptible,  but,  as  can 
readily  be  understood,  the  disease  occurs  most  frequently  in  the  poor,  the 
dirty,  and  especially  in  children,  whose  bodies  are  so  often  in  warm 
climates  naked  and  unprotected,  and  who  do  not  appreciate  the  risks  of 
contagion. 

Morbid  anatomy  and  pathology. — The  yaw  granuloma  con- 
sists of  round  or  spindle-shaped  cells  in  a  delicate  and  scanty  stroma  of 
connective  tissue.  It  springs  from  the  papilla?,  which  are  much  enlarged, 
and  from  the  Malpighian  layer. 

Symptoms.— Ten  to  fourteen  days  after  infection,  and  after  a  week 
or  thereabouts  of  more  or  less  fever,  languor,  rheumatic  pain — often  very 
severe,  and,  coincident  with  the  decline  of  these  symptoms,  an  eruption 
appears  in  the  skin.  The  surface  becomes  dry  and  harsh,  with  here  and 
there  small  circular  patches  of  f urfuraceous  desquamation.  These  patches 
may  be  few  in  number  and  small,  or  they  may  be  more  numerous,  larger, 
and  tending  to  coalesce.  After  a  further  interval  of  a  few  days,  minute 
papules  appear  in  the  scurfy  patches,  their  eruption  often  being  accom- 
panied by  much  itching.  Increasing  in  size,  the  papules  burst  through  the 
epidermis,  appearing  like  minute,  red,  hemispherical  swellings,  having  at 
their  apex  a  speck  of  a  sulphur-yellow  viscid  material.  This  yellow 
material  gradually  extends  over  the  whole  of  the  little  swelling,  and, 
becoming  dry  and  darker  in  colour,  comes  to  form  a  complete  crust.  The 
papule  may  now  shrivel  up  and  disappear,  leaving  behind  it  a  small 
pigmented  spot.  On  the  other  hand,  it  may,  and  often  does,  continue  to 
enlarge,  forming  a  prominent  excrescence  varying  in  size  from  a  pea  to  a 
walnut,  or  even  larger.  No  matter  what  the  size  of  the  individual  yaw,  it 
is  always,  unless  injured,  covered  by  the  yellowish  or  brownish  crust, 
which  tends  to  still  further  darken  with  age.  If  the  crust  is  removed,  the 
yaw,  as  these  sores  are  called,  is  seen  to  consist  of  a  red,  smooth,  rather 
soft,  slightly  bleeding,  insensitive  mass,  exuding  a  yellowish  gummy 
material,  which  speedily  dries  and  becomes  converted  into  a  fresh  crust. 
These  encrusted  excrescences  sometimes  attain  a  considerable  size,  perhaps 
in  a  few  instances  as  much  as  an  inch  to  an  inch  and  a  half  in  diameter 
and  about  three-quarters  of  an  inch  in  height.  When  large  they  are  flat 
on  the  top,  and  have  somewhat  rounded,  everted  edges ;  when  small  they 
are  roughly  hemispherical.  Sometimes  the  yaw  forms  a  ring  surrounding 
a  patch  of  healthy  skin.  Occasionally  several  yaws  coalesce,  particularly 
around  the  mouth,  the  nostrils,  or  on  the  nates.  In  these  latter  situations 
the  surface,  being  prone  to  excoriation,  is  often  raw  and  imperfectly 
encrusted.  When  yaws  form  on  the  sole  of  the  foot,  owing  to  the  difficulty 
they  have  in  breaking  through  the  thick  epidermis,  they  spread  out 
laterally,  attain  a  large  size,  and  cause  much  pain,  until  the  skin  has  been 
broken  through  and  the  granuloma  has  erupted. 

In  ordinary  circumstances  the  individual  yaw  lasts  for  six  weeks 
or  thereabouts ;  it  then  shrivels  up,  the  crust  falls  off,  and  a  small  pig- 
mented scar  remains.     Occasionally  a  yaw  breaks  down  and  ulcerates. 

The  number  of  yaws  varies  from  one  to  hundreds.  The  disease  may 
cease  on  the  healing  of  the  first  crop ;  usually,  however,  fresh  eruptions 
occur  from  time  to  time,  each  relapse  being  preceded  by  a  return  of  the 


VERRUGA.  289 

fever  and  rheumatic  pains  already  referred  to.  In  time  the  eruptions 
become  more  sparse,  and  gradually  cease  to  recur. 

An  ulceration  of  the  soft  palate  and  nose  has  been  described  as  a 
sequel  of  this  disease.  Some  contend  that  this  ulceration  is  of  syphilitic 
origin,  but  as  it  is  met  with  in  Fiji,  where,  according  to  Daniels,  syphilis  is 
unknown  among  the  natives,  this  cannot  be  the  case. 

Yaws  is  never  congenital ;  it  is  not  transmitted  from  mother  to  infant, 
or  from  infant  to  mother,  unless  by  direct  inoculation  of  the  specific  yaws' 
discharge  into  a  breach  of  surface. 

Diagnosis. — The  presence  of  a  lesion,  such  as  described,  following 
fever  and  severe  rheumatic-like  pains,  and  occurring  in  the  endemic  area,  is 
diagnostic.  There  should  be  no  difficulty  in  distinguishing  yaws  from  any 
of  the  polymorphic  lesions  of  syphilis.  For  many  reasons,  including 
absence  of  polymorphism,  yaws  is  manifestly  not  a  form  of  syphilitic 
disease,  as  some  hold.  In  yaws  there  is  no  primary  sore,  no  visceral 
disease,  no  gumma,  no  nerve  lesions,  no  alopecia,  no  secondary  sore  throat, 
no  congenital  lesions ;  there  is  only  one  lesion,  the  yaw. 

Prognosis. — As  affecting  life,  yaws  is  not  a  serious  disease.  In  the 
cachectic,  however,  the  phagedenic  type  of  ulceration,  so  common  in  the 
tropics,  may  attack  the  sores  and  prove  dangerous.  According  to  Daniels, 
the  average  duration  of  the  disease  is  about  one  year ;  some  cases  may 
terminate  in  two  or  three  months,  whilst  others  may  go  on  for  as  many 
years. 

Treatment. — During  the  febrile  rheumatic  stage,  everything  should 
be  done  to  encourage  free  eruption ;  warm  baths,  warm  clothing, 
diaphoretics  such  as  guaiacum,  acetate  of  ammonia,  and  warm  drinks  are 
useful.  Occasional  aperients  in  moderation,  of  which  sulphur  electuary  is 
a  favourite,  are  also  of  use.  When  the  yaws  appear,  some  antiseptic 
ointment  may  be  laid  on  the  sores.  The  food  ought  to  be  good  and  plenti- 
ful ;  tonics  may  be  administered  from  time  to  time.  Iodide  of  potassium 
and  mercury  tend  to  cause  involution  of  the  tumours,  but  they  do  not, 
apparently,  materially  shorten  the  duration  of  the  disease  or  prevent 
relapse. 

Isolation  of  the  sick,  the  protection  of  the  body  by  clothes,  the  cover- 
ing up  of  open  sores,  the  destruction  of  soiled  clothing,  and  such  obvious 
measures  for  preventing  contagion,  should  be  enforced. 

PATEICK  MANSON". 


VERRUGA. 

In  some  of  the  lofty  valleys  of  the  Andes  in  Bolivia  and  Peru,  a  disease 
resembling,  if  not  identical  with,  yaws,  and  locally  known  as  "  verrugas,"  is 
to  be  found.  The  same  fever,  the  same  rheumatic-like  pains,  and  similar 
granulomatous  excrescences  on  the  skin,  are  present  as  in  yaws  ;  but  in  a 
large  number  of  instances  in  verruga  the  fever  and  the  rheumatic  pains 
are  much  more  severe  and  prolonged,  and  the  skin  lesion  exhibits  a 
remarkable  tendency  to  bleed  not  seen  in  ordinary  yaws.  Oftentimes  the 
haemorrhage  is  so  frequent  and  so  profuse  that  a  profound  anaernia  results, 
and  death  is  by  no  means  uncommon.  The  higher  the  altitude  the  more 
severe  the  disease,  and  the  greater  the  liability  to  haemorrhage.  This  is 
vol.  1.— 19 


29o  GENERAL  DISEASES. 

well  understood  in  the  endemic  districts ;  so  that  patients,  where  possible, 
descend  to  the  sea-coast  in  order  to  diminish  the  risk.  It  is  said  that 
verruga  is  contracted  only  in  certain  limited  districts.  One  place  in 
particular,  called  Agua  de  Verrugas,  has  a  very  evil  reputation  in  this 
respect ;  simply  passing  through  this  district,  it  is  stated,  may  be  enough 
to  confer  the  disease,  which  here  is  said  to  attack  domestic  animals  as  well 
as  man. 

PATRICK  MAXSOK 


MALAEIA  AND  MALARIAL  DISEASE. 

The  term  malaria  is  virtually  synonymous  with  Plasmodium  malarice x — 
a  protozoon  of  warm  climates,  parasitic  in  man  and  in  certain  species  of 
mosquito.  In  man  it  inhabits  the  red  blood  corpuscles,  and  gives  rise  to 
a  special  type  of  disease — malarial  disease.  Malarial  disease  is  charac- 
terised by  fever  usually  of  a  periodic  character,  anaemia,  enlargement  of 
the  spleen,  and  the  deposit  in  the  tissues  of  a  black  pigment — melanin. 
Within  the  human  body,  the  parasite,  and  consequently  the  disease  it 
gives  rise  to,  are,  to  a  certain  extent,  amenable  to  quinine. 

History. — Early  in  the  history  of  medicine  (Hipppocrates,  460-377b.c.) 
fevers  were  already  divided  into  continued  and  intermittent,  that  is 
malarial  fever.  Later,  in  the  first  century  of  the  Christian  era,  clinical 
observation  had  arrived  at  distinguishing  tertian  from  quartan  intermittents 
(Celsus).  Modern  advance  in  the  knowledge  of  malarial  disease  may  be 
said  to  date  from  the  introduction  in  1640  of  cinchona  into  Europe  from 
South  America  by  Cinchon,  Viceroy  of  Peru ;  this  drug  supplied  a  valuable 
therapeutical  test  by  which  malarial  fevers  could  be  distinguished  from 
non-malarial  fevers  with  greater  certainty  than  by  their  clinical  features 
alone.  Subsequent  important  steps  in  the  history  of  the  subject  were  the 
recognition  of  the  malarial  nature  of  certain  pernicious  fevers  by  Torti, 
1712 ;  Lancisi's  investigations  in  etiology,  1716  ;  the  recognition  of  splenic 
enlargement  as  an  important  feature  in  the  pathology  of  paludism,  by 
Anduard,  1803  to  1823;  the  discovery  of  melaneemia  by  Meckel,  1847; 
and,  most  important  advances  of  all,  the  discovery  of  the  malarial  parasite 
by  Laveran,  1880,  and  of  the  role  of  the  mosquito  as  its  definitive  host,  by 
Ross,  1898. 

Etiology. — The  etiology  of  malaria  may  be  conveniently  treated  under 
three  heads : — (1)  The  parasite.  (2)  The  physical  conditions  favouring  the 
multiplication  and  diffusion  of  this  parasite  in  external  nature.  (3)  The 
conditions  favouring  (a)  its  introduction  into,  and  (b)  its  multiplication  in 
man. 

The  parasite. — This  protozoal  organism  belongs  to  the  Sporozoa,  order 
Hsemamcebidia.  In  habit  and  structure  it  is  closely  allied  to  the  Coccidia ; 
like  these  it  is  an  intracellular  parasite,  its  particular  cellular  habitat  in 
man  being  the  red  blood  corpuscles.  Many  of  the  lower  animals,  particu- 
larly birds  and  reptiles,  have  similar,  though  not  identical,  intracor- 
puscular  hsemoparasites.  So  far  as  is  certainly  known,  the  Plasmodium 
malarias  is  peculiar  to  man.  Seeing,  however,  that  the  plasmodium,  as 
seems  to  be  indicated  by  circumstantial  evidence,  may  have  an  existence 

1  Zoologically  the  malaria  parasite  is  not  a  plasmodium.  The  only  justification  for  con- 
tinuing the  use  of  the  term  is  that  it  is  now  almost  universally  applied  to  this  organism. 


MALARIA  AND  MALARIAL  DISEASE.  291 

independently  of  man,  it  is  more  than  probable  that  it  has  an  additional 
host  or  hosts  in  outer  nature  belonging  also  to  the  animal  kingdom ;  indeed, 
the  same,  or  a  closely  allied,  organism  has  been  found  in  bats  by  Dionisi, 
and  in  monkeys  by  Koch.  In  the  blood  corpuscles  of  man  the  plasmodium 
exhibits  two  distinct  phases,  one  (a)  manifestly  adapted  for  the  multiplica- 
tion and  continuation  of  the  organism  in  man ;  the  other  (b)  in  preparation 
for  that  phase  of  its  life  which  is  passed  outside  the  human  body.  For 
convenience  these  two  phases  may  be  designated  respectively  intracorporeal 
and  extracorporeal. 

Intracorporeal  phase. — There  are  several  varieties,  or  it  may  be 
species,  of  plasmodia,  each  with  a  life-cycle  of  more  or  less  definite  duration 
— either  of  twenty-four  (a  rare  form),  of  forty -eight,  or  of  seventy-two  hours' 
approximate  duration.  These  varieties  or  species,  although  differing  in 
minor  morphological  detail  as  well  as  in  the  duration  of  their  respective 
life-cycles,  are  all  of  them,  so  to  speak,  constructed  and  developed  on  the 
same  biological  lines. 

Though  for  a  brief  space  during  its  earliest  stage  as  spore,  the  plas- 
modium— then  a  minute,  colourless,  transparent  sphere  (Fig.  38,  /) — is 
free  in  the  blood  plasma,  it  quickly  enters  on  intracellular  life  by  first 
attaching  itself  to  and '  then  penetrating  a  red  blood  corpuscle  (Fig.  38,  a). 
The  young  parasite,  by  assimilating  the  haemoglobin  in  which  it  is  now 


CL,  b-  c.  d.  Q.  g. 

Fig.  38. — Parasite  of  tertian  malaria. 

embedded,  increases  rapidly  in  size,  exhibiting  at  the  same  time  active 
amoeboid  movement  (Fig.  38,  b).  Presently,  grains — sometimes  little  rods — of 
an  intensely  black  or  very  dark  red  pigment  (melanin)  appear  in  increasing 
numbers  in  the  colourless  hyaline  substance  constituting  the  growing 
parasite  (Fig.  38,  c).  These  pigment  particles  exhibit  slow  translation  move- 
ments of  their  own,  as  well  as  changes  of  position  brought  about  by  the 
amoeboid  movements  of  the  parasite.  When  the  plasmodium  has  about 
attained  its  full  size,  which,  according  to  species,  may  be  quarter,  or  half,  or 
even  greater  than  that,  of  an  ordinary  blood  corpuscle,  the  pigment  can  be 
seen  scattered  irregularly  throughout  its  substance  (Fig.  38,  d) ;  but  when 
the  parasite  is  quite  full  grown,  the  amoeboid  movements  cease,  and  the 
pigment  grains  become  concentrated  into  one  or  two  clumps  located  usually 
about  the  centre  of  the  little  organism  (Fig.  38,  e).  The  protoplasm  forming 
the  mass  of  the  animal  now  divides  into  spherules,  which  vary  in  number 
and  size  according  to  species ;  these  are  the  spores.  The  pigment,  being 
excrementitious  or  residual  matter,  does  not  partake  in  this  process  of 
division,  but  remains  isolated  and  passive.  The  mature,  sporule-bearing 
plasmodium  thus  constituted  is  usually  called  a  "  rosette  "  body.  On  the 
completion  of  sporulation,  the  blood  corpuscle  in  which  the  parasite  had 
developed  disintegrates,  and  the  contained  plasmodium  becomes  free  in  the 
blood  (Fig.  38,  /).  The  spores  then  fall  apart ;  such  of  them  as  escape  the 
phagocytes  enter  fresh  blood  corpuscles  and  repeat  the  cycle.  The  pigment 
and  many  of  the  spores  are  taken  up  by  the  phagocytes. 


292  GENERAL  DISEASES. 

It  is  to  be  noted  that  the  piasmodia  tend  to  occur  in  the  blood  in  crops 
or  swarms,  all  the  parasites  composing  a  particular  swarm  being  about  the 
same  age,  size,  and  stage  of  development.  The  parasites  of  each  swarm, 
therefore,  mature  and  sporulate,  approximately,  simultaneously,  the  success- 
ive generations  maturing  about  the  same  hour  daily,  or  every  second  or 
every  third  day,  according  to  species.  Two  or  three  swarms  of  different 
ages  may  be  present  at  the  same  time ;  so  that  double  infection  by  a  forty- 
eight  hour  parasite  will  have  one  swarm  maturing  to-day,  another  to-morrow. 
A  treble  infection  with  a  seventy-two  hour  parasite  will  show  a  similar 
quotidian  sporulation. 

By  staining  the  parasite  with  methylene-blue  or  other  suitable  pigment, 
its  minute  structure  is  revealed  (Fig.  39).  From  the  spore  to  the  adult 
stage  it  is  unicellular  (Fig.  39,  a-d).  The  cell  consists  of  (1)  a  nucleolus 
rich  in  chromatin  and  eccentrically  placed  in  (2)  a  vesicular,  unstaining 
nucleus;  and  (3)  an  outer  zone  of  colourable  protoplasm  in  which  the 
melanin  particles  are  located.  For  a  short  time  before  sporulation,  nucleus 
and  nucleolus  are  not  discoverable,  having,  by  karyoldnetic  division  (?)  or 
otherwise,  become  fragmented  and  diffused  through  the  mass  of  the  parasite 
(Fig.  39,  e) ;  subsequently  they  reappear  as  the  nuclei  and  nucleoli  of  the 
spores  (Fig.  39,/). 

Extracorporeal  phase. — Af ter  blood  from  the  subjects  of  malarial  inf ec- 


Fig.  39. — Evolution  of  the  benign  tertian  parasite. — Compiled 
from  Mannaberg. 

tion  has  been  on  the  microscope  slide  for  some  time,  in  addition  to  the 
foregoing  forms  a  peculiar  multiflagellated  organism  (Fig.  40,  c ;  Fig.  41,  e), 
displaying  great  activity,  is  sometimes  encountered.  From  the  characters 
of  the  bioplasm  of  which  it  is  principally  composed,  and  of  the  melanin 
particles  it  contains,  as  well  as  from  other  considerations,  it  is  evident  that 
this  singular  body  is  a  phase  of  the  plasmodium.  If  we  examine  malarial 
blood  often  enough  and  at  suitable  times,  sooner  or  later  we  will  encounter 
the  flagellated  body  in  process  of  development,  and  learn  that  it  is 
evolved  from  certain  free  spherical  piasmodia  (Fig.  40,  b;  Fig.  41,  c,  d). 
We  may  further  learn  that  these  free  spherical  piasmodia  originate  in 
one  of  two  ways,  according  to  the  species  or  variety  of  plasmodium  to 
which  they  belong.  In  what  are  known  as  the  quartan  and  benign  tertian 
parasites,  the  flagellated  body  originates  from  a  sphere  which  originally 
resembled  an  ordinary  full-grown  intracorpuscular  plasmodium  (Fig.  40,  a) ; 
in  what  may  be  designated  the  malignant  parasites  it  originates  from  a 
peculiar  form  of  the  plasmodium  called  the  "crescent  body"  (Fig.  41,  a). 

In  the  case  of  the  quartan  and  benign  tertian  parasites,  a  full-grown 
plasmodium  (Fig.  40,  a)  may  sometimes  be  seen  to  escape  from  a  red  blood 
corpuscle — the  corpuscle  in  which  it  had  developed — and  assume  a  spherical 
form  (Fig.  40,  b).  By  and  by  the  pigment  it  contains  becomes  agitated,  as 
it  were,  being  driven  hither  and  thither  by  some  unseen  force,  the  entire 
parasite  the  while  rapidly  changing  shape  and  becoming  violently  jerked 


MALARIA      ND  MALARIAL  DISEASE. 


293 


about.     Presently  one  or  more  long  flagella  are  suddenly  projected  from 
its  periphery  (Fig.  40,  c),  and  im- 
mediately commence  to  wave  about 
in  a  characteristic  manner. 

In  the  case  of  the  malignant  ter- 
tian and,  possibly,  other  varieties  of 
what  are  known  as  aestivo-autumnal 
plasmodia,  the  sphere  from  which  the 
flagellated  body  is  evolved  is  derived, 
as  stated,  from  the  crescent  body  (Fig. 
41,  a).  This  body  is  also  intracor- 
puscular;  but,  unlike  the  other  in- 
tracorpuscular  forms,  it  does  not 
show  itself  in  the  blood  at  the 
commencement  of  the  active  mani- 
festations of  malarial  infection.  It 
does  not  appear  until  about  a  week 
or  ten  days  after  the  commencement 
of  acute  symptoms.  On  their  first 
appearance  the  number  of  crescents  Fig.  40 


Quartan. 


b. 


Tertian 

Evolution  of  the  flagellated  body  in 

is  small,  but,  as  time  goes  on,  they     f^te^ne^HewSsSrMiteS'~C°mpUed 
gradually  become   more   numerous ; 

then,  after  a  week   or   longer,  unless  there  is  recurrence  of  fever,  they 

gradually  begin  to  disappear  again.     This  "  crescent  body  "  is,  as  its  name 

implies,  shaped  like  a  crescent,  with  the  exception  that  the  horns  of  the 

crescent  are  more  or  less  rounded.     It  is  colourless 

/^  and  somewhat  glistening.     At  or  near  its  centre  a 

'  )%j      a  ■  cluster  of  melanin  granules  is  always  a  prominent 

W  feature.     By  careful  scrutiny,  especially  if  aided  by 

staining,  we  can  make  out  that  it  is  enclosed  in  the 

almost  colourless  remains  of  a  red  blood  corpuscle, 

part  of  which  can  be  seen  as  a  delicate  bow  uniting 

the  horns  and  bridging  across  the  concavity  of  the 

crescent. 

The  earlier  stages  of  the  crescent  body  are  not 
readily  recognisable  in  the  peripheral  blood,  if  indeed 
they  occur   there;  most  probably  the  crescent  is 
wholly  evolved  in  the  vessels  of  some  of  the  viscera — 
spleen,  bone  marrow  escaping  into  the  general  cir- 
culation when  approaching  maturity.    I  am  inclined 
to  agree  with  Mannaberg  in  regarding  the  crescent 
as  what  in  zoological  language  is  called  a  syzygium, 
that  is  an  organism  resulting  from  the  conjugation 
of   two   individual   organisms,   in    this    case    two 
ordinary  plasmodia  in  a  multiple  infection  of  a 
blood  corpuscle — no  unusual   occurrence.     I  like- 
wise   believe  that   the   spheres   from    which    the 
^uti^ftT'fllSSSd^ge^ted  bodies  of  tertian  and  quartan  infections 
body  from  the  crescent.      are  evolved  also  originate  in  a  double  infection  of 
a  corpuscle.     This  conjugation  of  two  parasites  I 
regard  as  the  circumstance  determining  the  peculiar  direction  taken  by 
development  in  those  of  the  plasmodia  that  are  destined  for  extracorporeal 
life. 


294  GENERAL  DISEASES. 

If  in  a  suitably  prepared  slide  the  crescent  body  be  watched,  it  can  be 
seen  in  the  majority  of  instances  to  slowly  change  shape,  becoming  oval 
(Fig.  41,  h),  then  spherical  (Fig.  41,  c),  the  remains  of  the  blood  corpuscle  at 
the  same  time  falling  away  and  leaving  the  parasite  naked  in  the  blood. 
In  a  variable  time,  usually  from  fifteen  or  twenty  minutes  after  the  blood 
has  been  mounted,  the  pigment,  which  has  now  arranged  itself  as  a 
distinct  ring  at  the  centre  of  the  sphere,  in  many  of  the  spheres  begins 
to  move.  These  movements,  at  first  slow,  become  progressively  more 
violent,  being  apparently  directed  to  breaking  through  a  delicate  and 
invisible  capsule,  which  at  this  stage  may  enclose  the  central  portion 
of  the  spherical  body.  At  first  this  hypothetical  capsule  resists  the 
efforts  which  the  pigment  appears  to  be  making;  presently,  however, 
it  seems  to  rupture,  and  the  pigment  it  hitherto  confined  becomes 
diffused  throughout  the  entire  sphere  (Fig.  41,  d).  Simultaneously  with 
this  the  central  and  pigment-bearing  part  of  the  parasite  becomes  jerked 
about,  repeatedly  and  rapidly  changing  shape.  Careful  observation, 
aided  by  staining,  shows  that  these  movements  are  produced  by  flagella 
which,  attached  to  the  central  pigmented  portion  of  the  sphere,  are  waving 
about  very  actively.  Finally  these  flagella,  bursting  through  the  delicate 
peripheral  capsule  of  the  sphere,  are  thrown  out  from  one,  two,  or  more 
points  in  the  periphery  of  the  little  body  (Fig.  41,  e).  Sometimes  the 
flagella  are  isolated,  sometimes  they  are  in  more  or  less  tangled  bundles. 
It  is  probably  in  consequence  of  the  efforts  of  the  flagella  to  erupt  that 
the  jerking,  agitated  movements  of  the  sphere  are  produced. 

In  both  types  of  flagellated  body  the  flagella  may  vary  in  number  from 
one  to  six,  or  even  more.  They  are  very  slender  and  of  great  length — 
three  to  five  times  that  of  the  breadth  of  a  blood  corpuscle.  Here  and 
there,  either  in  their  continuity  or  at  their  free  extremities,  they  may  be 
expanded  into  a  sort  of  bulbous  thickening  (Fig.  41,  e).  For  a  time  the 
flagella  remain  attached  by  one  end  to  the  parent  body,  vigorously 
waving  about,  and  lashing  and  bending  the  blood  corpuscles.  While  thus 
attached,  they  resemble  so  many  wriggling  eels  held  fast  by  their  tails. 
After  a  time,  many  or  all  of  the  flagella  break  away  and  swim  free  and 
independently  in  the  liquor  sanguinis.  They  continue  to  move  in  this 
way  for  a  considerable  time — two  hours  in  some  instances,  and  have  even 
been  seen  to  attack  leucocytes  (Eoss).  Those  flagella  which  do  not  succeed 
in  breaking  away  from  the  parent  body,  gradually  slow  down  in  their 
movements,  some  of  them  vanishing  as  if  by  slow  solution ;  others,  before 
vanishing  from  view,  coiling  themselves  up  like  the  tendrils  of  a  vine. 

The  residual  body  remaining  after  the  eruption  of  the  flagella  consists 
of  a  small  portion  of  protoplasm  which  now  contains  all  the  melanin. 
Its  movements  quickly  cease ;  very  generally  it  is  engulfed  by  a  phagocyte. 
Frequently  non-flagellated  spheres  and  the  flagellated  bodies  themselves 
are  attacked  by  the  phagocytes,  which,  however,  respect  the  crescent 
bodies,  and,  at  all  events  in  the  peripheral  circulation,  all  intracorpuscular 
plasmodia. 

The  spheres,  whether  crescent-derived  or  directly  escaped  from  the 
blood  corpuscles,  are  of  two  kinds — hyaline  and  granular;  the  hyaline 
alone  gives  rise  to  flagella,  the  granular  never  exflagellate. 

At  one  time  the  flagellated  forms  were  regarded  by  many  observers  as 
moribund  organisms  in  their  death  agony,  the  whole  series  of  remarkable 
phenomena  exhibited  by  them  being  supposed  to  have  no  reference  to  the  life 
history  of  the  parasite.     In  1894,  and  again  in  1896,  the  writer,  basing  his 


MALARIA  AND  MALARIAL  DISEASE.  295 

hypothesis  on  the  regularity  with  which  exflagellation  occurs  in  all  varieties 


Fig.  43. — Transformation  of  the  zygote  in  the  stomach 
wall  of  the  mosquito. — Alter  Grassi. 


Fig.  42. — a,  Mierogametocyte  emitting  four  microgametes  (flagella) ; 
b,  free  microgamete  ;  c,  fecundation  of  the  macrogamete  ;  d, 
zygote  (travelling  vermiculi). 

of  the  parasite,  and  on  the  suggestive  fact  that  it  occurs  only  when  the 
parasite  is  removed  from  the  human  body,  published  the  view  that  the  flagel- 
lated body  was  no  mori- 
bund organism,  but  that  it 
had  reference  to  the  extra- 
corporeal phase  of  the 
parasite.  Further,  con- 
sidering that  there  ap- 
peared to  be  no  provision 
in  the  structures  of  the 
parasite  which  would 
enable  it  to  escape  spon- 
taneously from  the  human 
body,  as  there  is  no 
evidence  that  it  is  ex- 
truded from  the  human  body  in  excretions  or  in  morbid  discharges, 
and  as  the  plasmodium,  like  all  parasites,  must  contrive  in  some  way  to 
keep  in  existence  as  a  species  by  passing  from 
host  to  host,  he  inferred  that  some  extraneous 
agency  must  come  into  operation  to  remove  it 
from  the  human  body.  The  plasmodium  being  a 
blood  parasite,  this  agency,  he  concluded,  must  be 
a  blood  sucker ;  and  from  considerations  based  on 
the  distribution  of  malaria  in  nature,  and  guided 
by  the  analogy  of  what  occurs  in  the  case  of 
Filaria  nocturna  in  similar  circumstances,  he 
further  concluded  that  this  blood  sucker  must  be 
the-  mosquito,  and  probably  a  particular  species 
of  mosquito. 

Working  on  the  lines  indicated  by  this  hypo- 
thesis, Ronald  Eoss  has  shown,  and  his  observa- 
tions have  been  abundantly  confirmed  as  well  as  £ 
extended  by  Grassi,  Bignami,  Celli,  Koch,  Daniels, 
and  others,  that  if  certain  species  of  mosquito 
belonging    to    the   genus   Anopheles  are  fed   on  „ 
malarial  blood,  spheres  and  flagellated  organisms  Fl0Gn  \te~^1nI^Z 
rapidly  form  in  the  stomach  of  the  insect,  and,     mosquito.— After  Ross, 
passing  into  the  wall  of   the   stomach,  undergo 

a  remarkable  process  of  development  eventuating  in  the  formation  of  a 
multitude  of  sporozoites  which  ultimately  find  their  way  into  the  cells  and 


296 


GENERAL  DISEASES. 


secretions  of  the  veneno-salivary  gland,  whence  they  are  transferred  to  the 
blood  of  any  human  being  the  insect  should  chance  to  attack.  Eoss  has 
found  that  an  exactly  corresponding  evolution  is  gone  through  by  the  flagel- 
lated and  spherical  forms  olProteosoma,a,  malaria-like  parasite  of  certain  birds 

(sparrows,  etc.),  but  that  in  this  case  the  appro- 
priate mosquito  host  belongs  to  the  genus  Culex. 
Direct  observation  of  the  human  parasites, 
supported  and  supplemented  by  the  analogy  of 
the  corresponding  parasites  of  birds  {Halter- 
idium  and  Proteosoma),  indicates  the  following 
as  the  complete  life  history,  intracorporeal  and 
extracorporeal,  of  the  malarial  parasite: — In 
its  earliest  phase  the  parasite  is  an  amcebula 
or  myxopod  (Fig.  38,  a),  which,  entering  a  red 
blood  corpuscle,  grows,  becomes  pigmented, 
and  develops  into  (a)  a  sporocyte  (Fig.  38,  d), 
or  (b)  into  a  gametocyte  (Fig.  38,/). 

(a)  The  sporocyte  divides  into  a  number  of 

naked  spores  (Fig.  40  and  Fig.  41,  a),  which,  on 

Fig.    45.  -a    Rupture    of   zygote  bei        get   f  enter  fregh    blood    corpuscles, 

cyst  into  the  body  cavity  or  the  ,         °  .  I     ,  t  ■• 

mosquito ;  b,  free  sporozoites.—  becoming  amcebula  once  more,  and  so  contmu- 

After  Grassi.  ing  the  process  in  the  human  body,  as  already 

described. 
(b)  The  gametocytes  (crescents,  and  the  large  intracorpuscular  forms 
which  do  not  sporulate)  obtain  their  opportunity  of  developing  by  being 
ingested  by  the  mosquito.  They  are  of  two  kinds,  hyaline  (male)  (Fig.  42,  a) 
and  granular  (female)  (Fig.  42,  c).  The  hyaline  emit  a  number  of  micro- 
gametes  (the  flagella),  which,  breaking  away  (Fig.  42, 1,  c),  seek  to  enter  the 
granular  gametocyte  (macrogamete).  One  microgamete  succeeds  in  effecting 
an  entrance.  Thereupon  the  macrogamete  as  a  result  of  this  act  of  im- 
pregnation changes  shape,  becoming  an  elongated,  spear-shaped  zygote  (Fig. 
42,  d),  the  pigment  granules  accumulating  at  its  broader  or  posterior  end, 
the  anterior  end  becoming  finely  pointed  (MacCallum).  The  zygote  thus 
formed  acquires  powers  of  locomotion,  penetrates  the  wall  of  the  mosquito's 
stomach,  and  becomes  lodged  in  the  meshes  of  the  muscular  layer  of  that 
organ.  There  it  assumes  a  spherical  or  oval  shape,  becomes  encapsulated, 
and  grows  rapidly — from  6  ft,  to  70  //, — the  nucleus  and  protoplasm  divid- 
ing up  into  a  number  of  blastophores.  On  the  surface  of  the  blastophores, 
slender,  spindle-shaped  sporozoites  are  now  developed  in  vast  numbers 
(Fig.  43).  The  blastophores  next  disappear,  and  the  capsule,  packed  with 
sporozoites,  protrudes  like  a  wart  on  the  external  wall  of  the  stomach 
(Fig.  44).  The  capsule  then  ruptures,  and  the  sporozoites  escape  into 
the  body  cavity  of  the  insect  (Fig.  42,  a,  b),  whence,  as  already  stated,  they 
find  their  way  into  the  blood,  and  finally  into  the  cells  and  ducts  of  the 
veneno-salivary  gland,  to  be  injected  into  the  blood  of  any  human  being 
the  infected  mosquito  may  chance  to  attack.  From  a  week  to  ten  days 
after  being  bitten  by  an  infected  mosquito,  the  red  blood  corpuscles 
begin  to  exhibit  parasites,  and  the  clinical  phenomena  of  malaria  declare 
themselves. 

There  are  undoubtedly  several  forms  of  plasmodium;  but  whether 
these  are  specifically  distinct  one  from  the  other,  or  whether  they  are 
merely  transmutable  varieties,  is  still  an  open  question.  The  bulk  of 
opinion  is  in  favour  of  regarding  them — at  all  events  certain  of  the  forms 


MALARIA  AND  MALARIAL  DISEASE.  297 

— as  distinct  species.  The  table  on  p.  298,  modified  from  Mannaberg,  gives 
the  principal  characteristics  of  the  more  important  types. 

The  student,  in  order  to  acquire  a  working  knowledge  of  the  P.  mala/rice, 
must  avail  himself  of  every  opportunity  to  study  the  various  forms  of  the 
parasite  he  may  find  in  malarial  blood,  comparing  them  with  the  plates, 
and  with  the  descriptions  of  species  in  the  following  table.  If  he  does 
so,  he  will  with  practice  acquire  a  familiarity  with  its  microscopical 
appearances  of  the  utmost  value  in  the  diagnosis,  prognosis,  and  treatment 
of  malarial  disease. 

What  are  the  evidences  that  the  plasmodium  is  the  cause  of  malaria  ? 
First,  in  every  case  of  malarial  disease  which  has  not  been  treated  by 
quinine,  it  is  possible  to  find  the  plasmodium.  Second,  the  plasmodium 
has  been  found  in  causal  relationship  to  no  other  disease.  Third,  the 
cycle  of  the  plasmodium,  as  will  be  described  presently,  is  found  to  coin- 
cide with  the  cycle  of  the  special  form  of  fever  it  is  associated  with. 
Fourth,  melansemia  and  a  special  form  of  pigmentation  of  viscera  have 
long  been  regarded  as  pathognomonic  of  malaria ;  the  melanin,  the  source 
of  this  pathognomonic  feature,  is  manifestly  a  product  of  the  plasmodium. 
Fifth,  quinine,  which  cures  malarial  fever,  rapidly  causes  the  disappear- 
ance of  most  forms  of  the  parasite  from  the  blood;  not,  however,  the 
crescent-derived  forms,  which,  as  will  be  shown,  are  not  fever  forms. 
Sixth,  experimental  intravenous  injection  of  malarial  blood  is  followed 
by  malarial  fever  and  appearance  of  plasmodia  in  the  subject  of  the 
experiment.  Seventh,  the  bite  of  mosquitoes,  whose  salivary  glands  are 
known  to  contain  the  sporozoites  of  the  malaria  parasite,  is  followed  by 
the  appearance  of  the  malaria  parasite  in  the  blood  of  the  person  bitten 
and  by  the  clinical  phenomena  of  malaria. 

Physical  conditions  determining  geographical  distribution. — The 
distribution  of  malaria  is  regulated  by  the  physical  conditions  demanded 
by  the  particular  species  of  mosquito  subserving  the  parasite. 

As  already  stated,  these  mosquitoes  belong  to  the  genus  Anopheles. 
Evidence  is  accumulating  that  several  species  of  this  genus  are  efficient 
hosts.  In  Italy,  A.  claviger,  A.  pictus,  A.  bifurcatus,  and  in  India  A. 
rossii  have  all  been  incriminated.  Hitherto  the  malaria  parasite  of  man 
has  been  found  in  no  member  of  the  genus  Culex.  The  same  remark 
applies  to  the  various  species  of  the  other  genus  of  European  Culicidce, 
namely,  -JEdes. 

The  species  of  these  three  genera  of  mosquito  can  readily  be  recog- 
nised by  the  length  of  the  palpi  in  the  sexes.  In  Anopheles  the  palpi 
are  long  in  both  sexes,  equalling  in  length  the  proboscis  ;  in  Cidex  they 
are  long  in  the  male  insect,  but  very  short  in  the  female ;  in  JEdes  they 
are  short  in  both  sexes.  According  to  Ross,  Anopheles  when  at  rest 
poises  approximately  at  right  angles  to  the  surface  it  is  clinging  to ;  whereas 
in  similar  circumstances  the  body  of  Culex  is  on  a  parallel  plane.  Further, 
the  larva  of  Anopheles  when  breathing  lie  parallel  to  the  surface  of  the 
water  they  live  in ;  those  of  Culex  hang  head  downwards  at  right  angles  to 
it.  Anopheles  requires  puddles  of  water  in  which  certain  algte  are  growing ; 
Cidex  is  not  so  fastidious,  but  breeds  in  almost  any  collection  of  water. 

In  atmospheric  temperatures  below  60°  F.,  in  dry  sandy  deserts, 
and  on  board  ship  at  sea,  malarial  disease,  although  it  may  occur  as  a 
relapse,  is  never  contracted  for  the  first  time.  From  this  it  may  be 
inferred  that  Anopheles  requires  a  combination  of  warmth,  moisture,  and 
certain  as  yet  unknown  telluric  conditions. 


298 


GENERAL  DISEASES 


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MALARIA  AND  MALARIAL  DISEASE. 


299 


From  the  fact  that  within  the  endemic  belt  malaria  is  prone  to  occur 
in  low-lying  lands,  about  the  estuaries  of  great  rivers,  along  the  sea -board, 
in  jungle  lands,  and  in  swamps,  great  significance  has  been  attributed  to 
the  presence  of  decaying  vegetation  and  of  abundance  of  water  as 
generators  of  the  germ.  But  although  the  presence  of  decaying  vegetation 
is  a  frequent  concomitant,  and,  it  may  be,  a  favouring  condition,  neither 
this  nor  excessive  moisture  are  essential ;  for  malaria  is  common  enough 
on  many  dry  table-lands,  on  bare  rocky  places,  and  in  barren  spots  in  which 
water  is  scarce,  and  vegetation  is  of  the  most  meagre  description.  Neither, 
on  the  other  hand,  does  the  combination  of  heat,  moisture,  and  decaying 
vegetation  always  suffice  for  the  generation  of  malaria.  There  are  many 
places — certain  of  the  South  Pacific  Islands,  for  example — in  which  these 


(L.  b,  c.  d,.  e.  £, 

Fig.  46. — Parasite  of  quartan  malaria. 

conditions  all  coexist  in  a  high  degree,  and  yet  malaria  is  unknown. 
Manifestly,  the  conditions  required  by  Anopheles  are  of  a  very  complex 
character. 

Outside  the  human  body,  the  plasmodium,  regarded  as  simply  an 
organism  in  nature,  is  but  one  among  myriads  of  competing  forms.  The 
same  remark  applies  to  its  extracorporeal  host.  That  the  plasmodium 
and  its  extracorporeal  host  shall  survive  in  any  particular  locality  demands, 
therefore,  a  number  of  conditions.  First,  the  locality  must  afford  the 
meteorological  and  telluric  conditions  already  indicated  as  necessary ; 
second,  the  plasmodium  and  its  mosquito  host  must  predominate  over, 
or  hold  their  own  with,  such  competing  forms  of  life  as  may  happen  to 
coexist  in   the  locality ;    third,  their  enemies  must  be   few,  relatively 


c.  &.  c  cl.  e.         f 

Fig.  47. — Parasite  of  malignant  tertian  (sestivo-autumnal)  malaria. 

feeble,  or  absent.  The  plasmodium  is  a  part  of  nature,  and,  seeing  that  it 
has  to  live  in  external  nature  before  it  can  find  a  safe  asylum  in  man, 
is  subject  to  the  laws  of  survival  affecting  all  organisms.  These  con- 
siderations— the  presence  of  a  suitable  extracorporeal  host,  the  absence 
of  competing  forms,  and  the  absence  of  enemies — are  generally  lost  sight 
of  in  discussing  the  etiology  of  malaria;  nevertheless  they  are  only 
second  in  importance  as  affecting  the  distribution  and  presence  of  malaria 
to  temperature,  moisture,  and  soil. 

Most  probably  there  are  many  places  which  owe  their  healthiness,  not 
to  the  absence  of  telluric  and  meteorological  conditions  suitable  to  the 
extracorporeal  phase  of  the  plasmodium,  but  to  the  presence  of  some 
enemy  of  Anopheles,  or  some  competing  form  which  overpowers  it, 
and  so  keeps  it  under.     Studies  on  these  lines  have  not  been  commenced. 


3oo  GENERAL  DISEASES. 

Meanwhile  certain  facts  about  the  distribution  of  malaria,  which  in 
the  future  will  possibly  receive  their  explanation  by  such  studies,  are 
known.  Malaria,  although  it  has  occasionally  been  found  almost  as  far 
north  as  the  Arctic  Circle,  increases  on  the  whole  in  frequency  and  in- 
tensity as  the  Equator  is  approached.  It  is  not  evenly  distributed  over 
this  vast  area ;  on  the  contrary,  it  occurs  in  what  might  be  called  scattered 
pockets.  These  pockets  become  more  numerous  and  larger  in  area  towards 
the  Equator.  They  are  often  very  limited  in  extent;  being  confined  some- 
times, it  may  be,  to  a  few  square  yards.  Thus  one  house  may  be  malarious 
whilst  the  neighbouring  house  is  healthy ;  one  room  even  may  be  malarious 
whilst  the  other  rooms  in  the  same  house  are  not  so.  One  side  of  a  valley 
may  be  healthy,  the  other  unhealthy.  One  island  may  be  healthy,  a 
neighbouring  island  unhealthy.  In  our  ignorance  of  the  determining 
factors,  we  are  apt  to  regard  the  distribution  of  the  plasmodium  as 
capricious.  This  caprice  is  apparent  only ;  for  did  we  know  more  of  the 
life-history  of  the  plasmodium  outside  the  human  body,  more  about  its 
mosquito  hosts,  and  more  about  the  competing  forms,  this  apparent  caprice 
would  receive  a  rational  explanation.  Temperature,  moisture,  and  soil  are 
important,  but  they  are  not  the  whole  of  the  problem. 

The  difference  in  frequency  of  malaria  in  warm  as  compared  to  cooler 
countries  is  in  great  measure  dependent  on  atmospheric  temperature. 
This  being  so,  altitude,  inasmuch  as  it  usually  implies  lower  temperature, 
should  also  diminish  malaria ;  and  this  is  generally  the  case,  for  experience 
has  shown  that  on  the  whole  the  hills  are  healthier  than  the  plains.  Ex- 
ceptions to  this  rule  are  numerous  enough,  for  altitude  per  se  has  no 
influence  on  malaria.  If  altitude  means  low  temperature,  then,  as  regards 
malaria,  it  makes  for  salubrity ;  but  a  valley  which  is  badly  drained,  hot, 
and  confined,  even  if  at  a  considerable  altitude,  may,  notwithstanding  its 
elevation,  be  malarious. 

The  influence  of  water  in  furthering  the  development  of  malaria  is 
generally  recognised.  "Waterlogging  of  the  soil  by  floods,  or  by  the  artificial 
raising  of  the  level  of  the  ground  water  through  systems  of  artificial 
irrigation,  canals,  embankments  and  so  forth,  is  dangerous.  These  things 
tend  to  make  what  was  a  dry,  healthy  country  a  damp  and  malarious 
one ;  doubtless  by  affording  good  breeding  opportunities  for  the  malarial 
mosquitoes.  Possibly  for  the  same  reason,  breaking  up  waste  lands  for 
cultivation;  allowing  ground  to  fall  out  of  cultivation;  earth-cutting  for 
railways,  roads,  canals,  foundations,  and  soil  disturbances  generally  are 
prone  to  be  followed  by  epidemics  of  malaria.  Covering  the  soil  as  with 
houses,  pavement,  tillage,  or  deep-flooding  with  water,  tends  to  suppress 
malaria. 

Malaria,  that  is  the  extracorporeal  host  of  the  plasmodium,  usually 
cannot  survive  transport  for  more  than  a  few  yards ;  nor  can  it  rise  more 
than  a  few  feet  above  the  spot  in  which  it  originated.  At  the  same  time, 
in  certain  unknown  conditions,  it  may  be  introduced  into  and  flourish  in 
places  previously  free;  as  happened,  for  example,  in  1867  at  Mauritius 
and,  later,  at  Eeunion.  Like  the  germ  of  smallpox  or  of  measles,  it  does 
not  retain  its  vitality  for  a  long  time,  or  for  a  considerable  distance  from 
its  source,  unless,  whether  intentionally  or  by  accident,  it  be  specially 
protected. 

In  tropical  countries  certain  seasons  and  years  are  more  malarious  than 
others;  but  the  unhealthy  season  is  not  the  same  for  every  country. 
In  some  it  is  the  dry  season,  in  others  it  is  the  rainy  season.     These 


MALARIA  AND  MALARIAL  DISEASE.  301 

apparent  discrepancies  are  explained  by  the  influence  on  the  breeding 
pools  of  Anopheles.  In  subtropical  countries  malarial  fevers  from  first 
infections  begin  to  show  themselves  in  the  early  summer,  and  are  most 
severe  in  late  autumn ;  fevers  from  first  infections  do  not  occur  during 
the  winter  and  spring. 

Circumstances  favouring  introduction  and  multiplication  in  man. 
— The  most  important  of  these  is  residence  in  a  malarial  locality.  There 
can  now  no  longer  be  any  doubt  that  the  malarial  parasite  is  sometimes,  if 
not  always,  injected  into  man  by  the  mosquito  during  haustellation.  There 
may  be  other  ways  by  which  it  can  be  acquired,  but  as  yet  we  have  no 
experimental  knowledge  of  such.  Boss  observed  in  mosquitoes  fed  on 
proteosoma-containing  blood,  and  similar  observations  have  been  made 
on  mosquitoes  fed  on  malarial  blood,  that  certain  of  the  zygote  capsules  in 
the  stomach  wall  of  the  insect  contained  large,  black,  sausage-shaped  bodies. 
These,  apparently,  undergo  no  development  in  the  mosquito  in  which  they 
occur ;  but  there  is  some  reason  for  supposing  that  they  represent  another 
phase  of  the  malarial  parasite,  one  functioning  as  a  resting  spore,  and 
intended  for  subsequent  development  either  in  man,  some  other  vertebrate, 
or  in  succeeding  generations  of  mosquitoes  independently  of  a  vertebrate 
intermediary.  One  can  conceive  that  such  bodies  might  lie  latent  in  soil 
or  water,  and  so  in  water  or  through  the  air  get  access  to  man,  other 
vertebrates,  or  to  the  mosquito. 

It  is  generally  believed  that  malaria  is  most  abroad  just  before  sunrise 
and  just  after  sunset;  experience  has  shown  that  exposure  in  malarious 
spots  at  these  times  is  apt  to  be  followed  by  malarial  infection.  The  fact 
that  sleeping  on  the  ground  in  malarious  localities  is  also  apt  to  be  followed 
by  infection,  tends  to  show  that  the  plasmoclium  is  most  abundant  in  the 
lowest  stratum  of  the  air.  These  and  other  considerations  have  their 
explanation  in  the  habits  of  the  mosquito,  the  nocturnal  habits  of  this 
insect,  together  with  the  fact  that  it  clings  to  the  neighbourhood  of  the 
ground;  that  the  plasmodium,  in  fact,  is  a  parasite  of  the  mosquito  as 
well  as  of  man. 

A  lowered  condition  of  vitality,  such  as  may  result  from  fatigue,  cold, 
damp,  exposure,  depressing  emotions,  idleness,  dissipation,  apparently  by 
depressing  resistance  favours  the  establishment  and  proliferation  of  the 
Plasmodium  once  it  has  obtained  a  lodgment  in  the  human  body. 

Age,  sex,  occupation. — Age  has  no  very  manifest  influence  upon  sus- 
ceptibility. Children  are  just  as  liable  as  adults ;  in  the  former  malaria 
is,  on  the  whole,  a  more  common  and  serious  disease  than  in  the 
latter.  Sex,  as  such,  has  no  special  influence ;  neither  has  occupation, 
though,  of  course,  those  engaged  in  working  the  soil  are  particularly  liable 
to  infection. 

Infection. — Malaria  is  not  directly  communicable  from  one  human 
being  to  another  by  any  natural  process  of  infection ;  but  if  blood  from  a 
malarial  subject  be  injected  into  the  circulation  of  a  non-malarial,  the 
latter,  after  an  incubation  period  of  from  eight  to  twelve  days,  will  very 
probably  have  an  attack  of  malarial  fever  of  the  same  type  and  associated 
with  the  same  variety  of  plasmodium  as  in  the  former. 

Immunity. — One  attack  of  malaria,  so  far  from  producing  immunity, 
is  generally  followed  by  subsequent  attacks ;  and  this  whether  the  attacks 
be  the  result  of  relapse  or  of  fresh  infection.  Observations  by  Koch, 
confirmed  by  Stephens  and  Christophers,  have  recently  shown  that  in 
intensely  malarial  districts  practically  all  the  young  children  have  malaria 


3o2  GENERAL  DISEASES. 

parasites  in  their  blood.  As  the  native  children  get  older,  their  blood  is 
progressively  less  liable  to  the  infection,  and  in  native  adults  the  parasite 
is  rarely  found.  Immunity  from  malaria  can  therefore  be  acquired. 
Whether  this  fact  can  be  turned  to  practical  account  has  not  been 
determined. 

Morbid  anatomy  and  pathology. — The  post-mortem  appear- 
ances in  malarial  fever  are  characteristic.  The  spleen  is  invariably 
enlarged,  sometimes  very  much  enlarged.  In  recent  cases  it  is  softened, 
almost  diffluent.  On  section  it  is  found  to  be  dark  brown  in  colour, 
what  is  called  "  pigmented."  The  liver  is  also  enlarged,  congested,  pig- 
mented, and  softened.  The  vessels  of  the  brain  are  full ;  the  grey  matter 
often  of  a  dark,  sometimes  of  a  leaden  hue.  The  marrow  of  the  spongy 
bones  is  also  dark  and  congested.  Minor  degrees  of  pigmentation  and 
congestion  are  found  in  the  lungs,  alimentary  canal,  and  kidneys. 

On  submitting  the  various  organs  mentioned  to  microscopical  examina- 
tion, plasmodia  and  their  product  melanin  are  found  in  great  abundance 
within  the  blood  vessels.  In  the  spleen  and  bone  marrow  the  parasites 
are  specially  abundant,  and  occur,  both  inside  and  outside  the  vessels, 
included  in  the  large  phagocytic  cells  proper  to  these  organs.  Some  of  the 
large  splenic  cells  may  contain  not  one  but  many  parasites  still  enclosed 
in  the  blood  corpuscles  in  which  they  had  developed,  also  parasites 
apparently  not  so  enclosed,  and  masses  of  pigment ;  they  may  also  contain 
melaniferous  leucocytes.  As  the  spleen  is  not  only  the  grave  for  defunct 
parasite-infested  blood  corpuscles,  but  also  a  principal  breeding-ground 
for  the  plasmodium,  the  blood  of  the  splenic  vein  is  richer  in  parasites 
and  melaniferous  cells  than  that  of  any  other  vessel  in  the  body.  The 
vessels  of  the  liver  likewise  contain  many  plasmodia  and  much  pigment ; 
pigment  grannies  can  readily  be  seen  scattered  in  and  along  the  vessels. 
The  capillaries  of  the  grey  matter  of  the  brain  are  sometimes  so  crowded 
with  parasite-infested  corpuscles  that  they  are  virtually  thrombosed  thereby. 
The  intestinal  mucosa,  the  epiploon,  and  the  kidneys  may  be  similarly 
affected,  though  to  a  slighter  extent. 

In  addition  to  the  melanin  pigment  which  is  so  prominent  a  feature 
in  the  histology  of  malaria,  and  which,  unless  in  the  spleen  and  bone 
marrow,  is  confined  to  the  vessels,  there  is  to  be  found  another  pigment — 
a  yellow  pigment.  This  yellow  pigment,  unlike  the  melanin,  is  not 
confined  to  the  blood  vessels,  but  is  deposited  in  the  cells  of  the  liver, 
spleen,  kidneys, — in  fact,  in  nearly  every  organ  and  tissue  of  the  body.  It 
occurs  in  the  protoplasm  of  the  cells  as  minute  grains.  Chemical  tests 
prove  it  to  be  slightly  altered  haemoglobin,  derived,  doubtless,  from  the 
blood  and  deposited  in  the  protoplasm  of  the  tissue  cells ;  just  as  happens 
in  many  other  diseases,  in  burns,  and  in  forms  of  poisoning  associated  with 
rapid  destruction  of  large  numbers  of  blood  corpuscles. 

In  malarial  cachexia,  unless  as  a  consequence  of  a  recent  malarial 
attack,  melanin  pigmentation  is  not  a  necessary  feature.  The  hypertrophied 
condition  of  the  spleen  is  largely  due  to  thickened  capsule  and  trabecular, 
rather  than  to  an  active  congestion ;  the  organ,  therefore,  is  hard  and 
tough  even.  In  the  same  way  the  liver  may  be  enlarged  from  simple 
congestion,  or  it  may  be  in  advanced  cases  the  subject  of  hypertrophic  or 
of  ordinary  cirrhosis.  The  kidneys,  too,  are  apt  to  become  cirrhotic, 
or  fatty.     The  heart  is  often  degenerated  and  dilated. 

The  destruction  of  the  blood  corpuscles  by  the  proliferation  and  growth 
of  the  plasmodium  explains,  in  great  measure,  the  anaemia  which   is  so 


MALARIA  AND  MALARIAL  DISEASE.  303 

constant  a  sequela  of  acute  malarial  attacks.  The  fall  in  the  corpuscular 
richness  of  the  blood  after  even  a  single  fever  parox)7sm,  more  especially 
after  haemoglobinuric  attacks,  is  enormous,  amounting  sometimes  to  as 
much  as  500,000  per  c.nmi.  A  very  few  such  paroxysms,  therefore, 
suffice  to  bring  the  blood  count  down  to  2,000,000,  or  even  to  1,000,000. 
At  the  same  time  the  haemoglobin  value  of  the  remaining  corpuscles  is 
seriously  reduced. 

Judging  merely  from  the  relatively  scanty  stock  of  plasmodia  usually 
visible  in  the  peripheral  circulation,  it  would  be  difficult  to  account  for  an 
anaemia  of  so  extreme  and  so  rapidly  developed  a  character.  It  must  be 
borne  in  mind,  however,  that  the  principal  nidus  of  the  parasite  is  the 
blood  vessels  of  the  viscera  and  bone  marrow,  not  the  peripheral  cir- 
culation. In  these  organs,  as  already  explained,  plasmodia  are  generally 
present  in  enormous  numbers,  even  although  they  may  be  scanty,  or,  for  a 
time,  perhaps  altogether  wanting  in  finger  blood. 

The  pigmentation  of  organs,  so  characteristic  of  malaria,  is  evidently 
derived  from  the  melanin  manufactured  by  the  plasmodium,  and  liberated 
on  the  breaking  up  of  the  sporulating  bodies.  It  is  derived  both  from 
parasites  developed  locally,  and  from  plasmodial  pigment  liberated  in  the 
peripheral  circulation,  and  carried  by  the  leucocytes  to  the  spleen  and  other 
pigmented  viscera,  and  there  deposited.  The  endothelium  of  the  vessels, 
as  well  as  the  white  blood  corpuscles,  exercises  a  phagocytic  function  as 
regards  malarial  infection. 

The  fever  in  malaria  is  doubtless  produced  by  a  parasite-elaborated 
toxine  liberated  at  the  moment  of  breaking  up  of  the  sporulating 
bodies.  This  conjecture  is  countenanced  by  the  fact  that  the  oncoming  of 
fever  concurs,  in  the  main,  with  this  act  in  the  plasmodial  drama.  I 
believe  that  this  febrogenetic  toxine,  or  another  toxine  liberated  by  the 
Plasmodium,  exerts  a  solvent  action  on  the  haemoglobin  not  only  of  those 
corpuscles  which  harbour  parasites,  but  also  on  the  haemoglobin  of  the  other 
and  apparently  healthy  corpuscles.  Hence  the  marked  diminution  which 
is  observable  in  the  haemoglobin  value  of  the  surviving  red  blood  cor- 
puscles. 

The  bilious  symptoms,  often  so  prominent  a  feature  in  malaria,  are  the 
result  of  an  excessive  secretion  of  bile ;  the  excess  of  bile  in  its  turn 
depending  on  the  excess  of  haemoglobin  in  the  blood  plasma.  When  the 
haemoglobin  reducing,  bile  forming  capacity  of  the  liver  is  unable  to 
overtake  the  rapid  and  excessive  liberation  of  haemoglobin,  a  haemoglob- 
inaemia  results.  The  free  haemoglobin  is  then  deposited  in  the  tissues, 
tingeing  the  skin  and  giving  rise  to  malarial  hematogenous  jaundice.  If 
the  amount  of  liberated  haemoglobin  be  in  still  greater  excess,  it  escapes  by 
the  kidneys,  giving  rise  to  haemoglobinuria,  to  choking  of  the  kidney  tubules, 
and  perhaps  in  this  way  leading  to  suppression  of  urine  or  to  nephritis. 

Symptomatology. — The  incubation  period  in  malaria  is  subject  to 
very  great  variation.  Probably  eight  to  ten  days  is  the  minimum.  The 
maximum  may  extend  to  years,  for  clinical  manifestations  of  infection 
may  not  show  themselves  for  a  very  long  period  after  the  endemic 
malarial  region  has  been  quitted.  During  the  interval  the  parasite  must 
lie  in  the  tissues  in  some  as  yet  unknown,  passive  form ;  the  condition  in 
these  circumstances,  therefore,  is  rather  one  of  latency  than  of  incuba- 
tion. 

Explosions  of  latent  malarial  infection  may  take  place  from  time  to 
time  without  very  obvious  cause ;  as  a  rule,  however,  they  are  generally 


304  GENERRL  DISEASES. 

provoked  by  some  physiological  strain  such  as  may  be  produced  by  chill, 
fatigue,  excesses,  injuries,  mental  shock,  disease;  in  fact,  by  anything 
calculated  to  upset  the  general  health,  or  to  depress  the  normal  powers  of 
resistance. 

Intermittent  fever. — However  brought  about,  whether  by  a  recent  or 
by  a  latent  infection,  the  presence  and  active  propagation  of  the  plasmodium 
in  the  circulation  are  associated  with  certain,  usually  well-marked,  clinical 
phenomena.  Of  these,  fever  of  a  special  type  is  a  leading  one.  This  fever, 
as  is  the  case  with  most  of  the  clinical  phenomena  associated  with  the 
Plasmodium,  has  a  marked  tendency  to  assume  a  cyclical  character. 

The  typical  clinical  malarial  cycle  is  either  one  of  twenty-four  hours, 
in  which  case  it  is  called  "  quotidian " ;  or  of  forty-eight  hours,  when  it 
is  called  "  tertian  " ;  or  of  seventy- two  hours,  called  "  quartan."  An  im- 
portant pathological  fact  in  this  connection  is,  that  these  fever-cycles 
correspond  in  spacing  with  the  life-cycles  of  the  particular  varieties  of 
Plasmodium  producing  them.  Thus  the  quartan  fever  is  produced  by  a 
parasite  of  seventy-two  hours'  cycle ;  the  tertian,  by  a  parasite  of  forty- 
eight  hours'  cycle ;  the  quotidian,  by  the  quotidian  parasites  or,  more 
generally,  by  two  swarms  of  tertian  parasites  maturing  on  alternate  days, 
or  by  three  swarms  of  quartan  parasites  maturing  on  three  successive 
days,  or  by  a  mixed  infection  of  quartan  and  tertian  parasites. 

The  clinical  cycle  may  be  said  to  commence  with  the  onset  of  fever. 
This  in  point  of  time,  and  doubtless  of  causation,  corresponds  with  the 
breaking  up  in  the  blood  of  the  sporulating  plasmodia.  It  is  signalised  by 
a  rise  of  temperature,  headache,  desire  to  stretch  the  limbs,  chilliness,  and 
the  usual  accompaniments  of  approaching  febrile  illness.  Presently — 
the  thermometer  having  already  risen  several  degrees — violent  rigor  sets 
in,  the  teeth  chatter,  and  the  body  becomes  almost  convulsed  with  shiver- 
ing. .  There  is  cutis  anserina ;  the  pulse  is  small ;  the  hands  and  feet  feel 
cold  to  the  touch,  and  look  shrivelled ;  the  features  are  blue,  or  pale  and 
pinched;  and  pale  limpid  urine  may  be  passed  in  large  quantities. 
Meanwhile,  notwithstanding  the  subjective  feelings  of  cold  characterising 
this,  "  the  cold  stage,"  the  temperature  in  the  central  parts  of  the  body 
— axilla,  mouth,  rectum — continues  to  rise.  Vomiting  may  occur.  After 
half  an  hour,  or  an  hour,  or  even  longer,  the  feeling  of  intense  cold  gradually 
gives  place  to  one  of  correspondingly  intense  heat.  The  head  throbs  and 
aches ;  the  face  is  flushed ;  the  hands  are  hot  and  dry ;  the  pulse  full, 
quick,  and  bounding ;  the  respiration  hurried.  Vomiting  may  be  frequent 
and  urgent ;  thirst  intense.  Urine  is  scanty  and  high-coloured.  Occa- 
sionally there  may  be  delirium.  This,  the  "  hot  stage,"  may  continue  for 
two  or  three  hours  or  even  longer.  The  temperature  before  the  fastigium 
is  attained  may  rise  to  104°,  106°,  or  even  to  107°  F.  or  over.  Then 
perspiration  begins  to  show  itself  about  the  neck,  forehead,  palms  of  the 
hands ;  gradually  extending,  it  bursts  out  over  the  entire  surface  of  the 
body.  Sweat  now  literally  pours  off  the  patient,  saturating  his  clothes 
and  even  the  bedding.  With  the  oncoming  of  this,  the  "  sweating  stage," 
febrile  distress  rapidly  abates,  the  temperature  falls  to  normal,  and  in  the 
course  of  an  hour  or  so  the  patient,  beyond  a  certain  feeling  of  lassitude, 
may  find  himself  quite  well,  able  in  mild  cases  to  be  up  and  to  attend  to 
his  work.  During  most  malarial  attacks  the  spleen  becomes  palpably 
swollen,  and  the  liver  may  also  be  similarly  affected,  though  to  a  less  degree ; 
both  organs  may  be  the  seat  of  discomfort  and  even  of  actual  pain. 

The  duration  of  one  of  these  paroxysms  of  fever,  which  when  of  this 


MALARIA  AND  MALARIAL  DISEASE.  305 

type  is  called  "  ague  "  or  "  intermittent  fever,"  varies  from  three  to  six  or 
eight  hours,  or  even  longer.  Its  degree  of  severity  is  equally  variable, 
ranging  from  fever  of  the  mildest  to  fever  of  the  most  intense  description. 
The  three  elementary  constituents  of  the  fever  fit  may  also  vary  in 
relative  severity  in  different  cases.  Thus  the  rigor  may  be  slight  or 
severe;  or  the  hot  or  the  sweating  stages  may  be  similarly  modified. 
Infinite  variety  obtains  in  this  respect.  Their  essential  characters,  however, 
are  the  same  whether  the  case  be  one  of  quotidian,  of  tertian,  or  of  quartan 

Assuming  that  the  patient  has  received  no  efficient  treatment,  we  will 
find  that  after  an  interval  of  complete  freedom  from  fever,  on  the  follow- 
ing, or  on  the  second,  or  on  the  third  succeeding  day,  and  commencing 
about  the  same  time  of  the  day,  an  exactly  similar  attack  takes  place. 
For  weeks  these  periodical  attacks  recur  with  the  utmost  regularity.  By 
and  by  they  may  diminish  in  severity,  and  gradually  cease  ;  but,  provided 
proper  treatment  is  not  instituted,  and  sometimes  even  in  spite  of  it, 
relapse  on  slight  provocation  is  nearly  sure  to  occur.  Occasionally,  though 
very  rarely,  in  a  quotidian  fever  caused  by  a  quartan  parasite,  one  of  the 
swarms  of  parasites  may  drop  out ;  then  the  fever  paroxysm  will  recur  on 
two  successive  days,  to  be  followed  by  a  day  free  from  fever.  Or,  in  a 
quotidian  ague  caused  by  a  tertian  parasite,  similarly,  one  of  the  swarm 
may  drop  out ;  then  the  quotidian  becomes  a  tertian.  Apparently  in  con- 
sequence of  mixtures  of  the  different  types  of  parasites — "  mixed  infections," 
there  is  great  variety  in  the  type  and  course  of  malarial  fevers,  especially 
if  owing  to  a  recent  infection.  Old-standing  fevers  are  usually  typical 
quotidian,  typical  tertian,  or  typical  quartan  agues. 

Fevers  may  tend  to  come  on  a  little  earlier  each  succeeding  day ;  in 
this  case  the  fever  is  said  to  "anticipate" — an  occurrence  regarded  as 
indicative  of  increasing  severity.  On  the  other  hand,  the  oncome  of  a 
fever  may  be  delayed  a  little  every  day;  the  fever  is  then  said  to 
"  postpone."  This  is  looked  on  as  an  indication  that  the  severity  of  the 
fever  is  lessening.  When  a  paroxysm  of  fever  is  prolonged  into  the 
following  day,  and  has  not  expended  itself  before  the  succeeding  attack  sets 
in,  the  fever  is  said  to  be  "  subintrant."  If  very  little  remission  occurs 
between  two  fever-cycles,  such  an  attack  is  called  "  remittent."  If  there 
be  no  remission  in  symptoms,  the  fever  is  called  "continued."  First 
attacks  of  malarial  fever,  particularly  in  the  tropics,  are  apt  to  be  of  this 
latter  character.  They  are  generally  either  remittent  or  continued,  rarely 
intermittent,  although,  on  the  subsidence  of  the  more  acute  phenomena, 
they  may  gradually  merge  into  a  genuine  intermittent  fever.  On  the  other 
hand,  in  more  temperate  climates,  even  first  attacks  are  usually  distinctly 
intermittent.  Intermittents  in  the  tropics  are  usually  quotidians,  that 
is  double  tertians ;  in  temperate  climates,  more  often  tertians.  Quartans 
are  rarer  both  in  temperate  and  in  tropical  countries ;  relatively  to  the 
number  of  cases  occurring,  they  are  proportionately  rarer  in  the  tropical 
than  in  the  temperate  zones.  The  relative  proportion  of  tertian  to 
quartan  infections  varies  very  much  with  locality  and  season. 

Irregular  and  larval  fevers. — Although  malarial  poisoning  finds  ex- 
pression, as  a  rule,  in  well-marked  ague,  or  in  some  form  of  so-called 
remittent  or  continued  fever,  yet  it  often  happens  that  the  presence  of  the 
Plasmodium  in  the  blood  is  not  so  acutely  or  definitely  signalised.  Feverish- 
ness  with  slight  or  well-marked  elevations  of  temperature,  accompanied  by 
greater  or  lesser  degrees  of  lassitude,  headache,  anorexia,  splenic  enlarge- 
vol.  1. — 20 


3o6  GENERAL  DISEASES. 

ment,  anaemia,  coming  and  going  at  short  but  somewhat  irregular  intervals 
of  a  day  or  two,  or  it  may  be  at  longer  or  more  or  less  regular  intervals 
of  one,  two,  or  three  weeks,  may  be  all  the  clinical  evidence  of  plasmodial 
infection.  The  parasite  in  such  cases  can  generally  be  found  in  the  blood, 
even  during  apyretic  intervals  of  considerable  duration.  Any  depressing  or 
exhausting  circumstance,  such  as  exposure,  or  irregularity  of  living,  and  so 
forth,  tends  to  favour  a  more  active  proliferation  of  the  plasmodium,  and 
consequently  more  acute  clinical  manifestations. 

Ordinary  agues,  remittents  and  continued  malarial  fevers,  although 
sometimes  giving  rise  to  extreme  debility  and  anaemia,  do  not  seriously 
endanger  life.  Occasionally,  however,  in  the  subtropics,  »but  more 
particularly  in  the  highly  malarious  districts  of  the  tropics,  and  especially 
in  the  case  of  infections  by  the  crescent-forming,  small-spored  plasmodia, 
malarial  disease  may  assume  a  grave  and  even  malignant  character.  These 
cases  form  an  important  clinical  group,  which  is  divisible  roughly  into  bilious 
remittent,  typho-adynamic,  and  pernicious  fevers.  The  pernicious  fevers 
are  sometimes  classified  into  cerebral  and  algid ;  the  latter  being  character- 
ised by  suddenly  developed  adynamic  symptoms  and  a  tendency  to  collapse, 
the  former  by  various  symptoms  attributable  to  grave  implication  of  the 
brain  and  nervous  system. 

Bilious  remittent. — This  type  of  malaria,  besides  being  accompanied 
by  the  usual  remitting  or  more  or  less  continued  fever,  is  specially  charac- 
terised by  symptoms  indicating  severe  implication  of  the  abdominal  viscera. 
There  is  a  great  amount  of  epigastric  discomfort;  marked  enlargement  of  the 
spleen;  slighter  enlargement  of  the  liver;  a  somewhat  swollen,  thickly- 
coated  tongue;  much  nausea;  much  vomiting  of  dark  bilious  material; 
severe  headache ;  thirst ;  anorexia ;  an  icteric  tint  of  skin  and  scleras ; 
sometimes  constipation,  sometimes  bilious  diarrhoea.  The  acute  symptoms 
under  proper  treatment  slowly  or  more  quickly  subside  in  the  course  of  a 
week  or  ten  days.  If  left  to  itself,  the  disease  may  spontaneously  and 
slowly  subside ;  or  it  may  merge  into  an  ordinary  intermittent,  or  into  the 
following : — 

Typho-adynamic  fever. — In  this  the  symptoms  assume  a  typhoid 
character.  They  may  be  asthenic  from  the  outset,  especially  in  the 
debilitated  and  cachectic ;  or,  having  commenced  as  an  ordinary  remittent 
or  intermittent,  the  sthenic  symptoms  after  a  time  give  place  to  those  of 
a  typhoid  and  asthenic  type.  The  patient  is  extremely  prostrate.  There 
may  be  low,  muttering  delirium ;  hallucinations ;  catching  at  imaginary 
objects;  picking  of  the  bedclothes;  subsultus;  dry  tongue;  sordes  in  the 
mouth ;  a  feeble,  running,  perhaps  dicrotic  pulse  and  other  indications  of 
the  typhoid  state.  Such  fevers  are  highly  dangerous ;  collapse,  or  more 
active  pernicious  symptoms,  may  at  any  time  suddenly  supervene.  They 
are  apt  to  be  complicated  by  a  low  and  very  dangerous  type  of  pneumonia, 
or  with  bedsores,  or  other  form  of  gangrene. 

Pernicious  attacks  may  occur  in  the  course  of  what  are  apparently 
ordinary,  and  perhaps  by  no  means  severe,  malarial  fevers.  Their  dis- 
tinctive marks  are  suddenness  of  onset  and  gravity. 

The  pernicious  nature  of  the  attack  seems  to  depend  on  a  variety  of 
circumstances — (1)  Embolic  plugging  of  the  capillaries  and  small  arteries 
of  important  organs  by  accumulations  of  plasmodia.  (2)  A  large  dose  of 
plasmodial  toxine  in  the  presence  of  a  special  susceptibility  depending 
either  on  personal  idiosyncrasy;  or  on  lowered  resistance  from  intemperance, 
hardship,  other  diseases ;  or,  and  especially,  on  previous  malarial  attacks. 


MALARIA  AND  MALARIAL  DISEASE.  307 

(3)  A  special  type  of  plasmodium ;  or  a  second  and  superadded  infection 
by  fresh  malarial  or  other  and  as  yet  unknown  germs. 

To  the  first  category  may  belong  hyperpyrexial,  comatose,  convulsive, 
paralytic,  gastric,  choleraic,  and  dysenteric  attacks ;  to  the  second,  syncopal 
and  colliquative  attacks ;  to  the  third,  hiemoglobinuric  attacks. 

Hyperpyrexial,  comatose,  convulsive,  and  paralytic  attacks. — It  occasion- 
ally happens  in  the  hot  stage  of  what  appears  to  be  an  ordinary  inter- 
mittent or  remittent,  and  without  obvious  reason,  that  hyperpyrexial 
temperature  is  rapidly  attained.  In  malarial  fevers,  high  temperatures, 
106°  or  107°,  are  not  uncommon;  provided  they  are  not  long  maintained, 
these  temperatures  are  not  specially  dangerous.  Beyond  this  point,  how- 
ever, there  is  grave  risk  to  life.  On  the  thermometer  reaching  106°  or 
107°,  the  patient  is  apt  to  become  delirious;  on  its  attaining  108°  he  may 
become  for  a  short  time  wildly  maniacal,  and  then  rapidly  lapse  into 
profound  coma  with  stertorous  breathing,  a  flushed  and  bloated  face,  and 
a  full  and  bounding  pulse,  which  rapidly  loses  its  sthenic  character,  and, 
becoming  weak,  flutters  and  stops.  Frequently  at  the  time  of  death 
temperatures  of  110°,  112°,  or  even  higher,  are  registered.  Those  hyper- 
pyrexial malarial  attacks  are  liable  to  be  misunderstood,  and  are  often 
called  "  sunstroke,"  "  heat  apoplexy,"  or  "  ardent  fever  " ;  this  is  a  serious 
mistake  if  the  diagnosis  should  imply  a  treatment  in  which  quinine  in  full 
doses  promptly  administered  is  not  included. 

Although  delirium,  coma,  and  convulsions  are  common  in  hyperpyrexial 
attacks,  they  may  also  supervene  in  fevers  in  which  there  is  no  unusual 
or  excessive  elevation  of  temperature.  Similarly,  aphasic  symptoms  of  a 
transitory  nature,  amaurosis  of  central  or  peripheral  origin,  and  other 
forms  of  cerebral  paresis,  are  occasionally  met  with.  The  leading  feature  in 
these  cases  seems  to  depend  on  the  particular  cerebral  centre  picked  out 
"by  the  embolic  plasmodia. 

Algid  attacks. — These  may  supervene  during  what  in  point  of  time 
would  be  the  hot  stage  of  an  intermittent.  The  patient  does  not  react 
after  the  cold  stage.  He  does  not  suffer,  but  he  is  profoundly  prostrate. 
The  skin  has  a  frog-like  feel,  being  cold  and  covered  with  a  clammy  sweat. 
The  tongue  and  breath  are  also  cold ;  the  pulse  is  rapid  and  small ;  the 
temperature  little,  if  at  all,  raised.  These  attacks  are  highly  dangerous, 
and  are  prone  to  end  in  fatal  asthenia. 

Diaphoretic  attacks. — In  these  the  terminal  sweating  of  an  ague  is 
very  much  exaggerated,  prostrating  the  patient  and  rendering  him  liable 
to  alarming  collapse,  or  to  syncope  on  rising  from  bed  or  on  making  the 
slightest  effort. 

Choleraic  attacks  may  occur  during  either  the  'cold  or  the  hot 
stage.  There  is  sudden  and  profuse  vomiting  and  diarrhoea,  a  choleraic 
countenance  and  voice,  suppression  of  urine,  and,  very  often,  cramps  in  the 
calf  muscles.  At  times  the  attack  ends  in  fatal  collapse.  The  stools  are 
always  to  some  extent  bilious,  and  do  not  assume  the  true  rice-water 
appearance  of  the  stools  of  true  cholera. 

Dysenteric  attacks. — These  may  occur  in  the  course  of  an  ague  fit, 
blood  being  passed  in  considerable  quantities  together  with  a  certain 
amount  of  mucus.  Tenesmus  and  the  usual  subjective  signs  of  dysentery 
may  also  be  present.  The  temperature  is  higher  than  it  usually  is  in  the 
acute  stage  of  true  dysentery — a  circumstance  which,  together  with  the 
history,  should  put  the  physician  on  his  guard  in  diagnosis. 

Hosmoglobinuric  fever. — In  certain   parts  of   the   tropical  world,  and 


308  GENERAL  DISEASES. 

in  some  malarial  spots  in  more  temperate  zones,  but  more  especially  in 
tropical  Africa,  a  form  of  what  is  generally  regarded  as  malarial  fever  is 
found,  to  which  the  names  of  "  blackwater  fever  "  or  "  haematuric  fever " 
are  commonly  applied.  In  tropical  Africa  this  disease  is  one  of  the 
commonest  causes  of  death  in  Europeans,  amounting  to  a  scourge  in  many 
parts  of  the  West  Coast,  on  the  banks  of  the  Congo,  and  on  the  Niger ; 
it  also  occurs  in  Nyassaland,  in  Mozambique,  on  the  Zambesi,  and  in  many 
parts  of  the  East  Coast.  It  is  common  in  Madagascar.  It  is  very  rarely 
heard  of  in  India,  but  it  occasionally  occurs  in  Assam,  Cochin-China,  Java, 
New  Guinea,  and  probably  elsewhere  in  the  Eastern  Hemisphere.  It 
occurs  also  in  the  West  Indies,  in  the  Southern  States  of  the  Union,  in 
Colombia,  and  in  Central  America.  It  is  occasionally  met  with  in  South 
Italy,  Sicily,  and  Greece. 

The  patient  has  usually  been  in  malarial  regions  for  a  considerable 
time,  and  has  suffered  much  from  malaria,  and  very  probably  is  anaemic 
and  debilitated.  During  the  course  of  what  he  at  first  regarded  as  one  of  his 
familiar  fevers,  he  feels  an  urgent  desire  to  pass  water.  He  notices  that  his 
urine  has  become  very  dark — like  Malaga  wine.  About  the  same  time 
that  the  urine  becomes  discoloured,  he  notices,  or  his  friends  remark,  that 
his  skin  and  scleras  have  assumed  a  deep  saffron-yellow  colour.  Vomiting 
of  dark  bilious  matter  sets  in.  He  suffers  from  bilious  diarrhoea,  or,  it 
may  be,  from  constipation.  There  is  severe  pain  in  the  liver,  spleen, 
epigastrium,  and  loins.  This  condition  after  a  time  may  subside,  the  urine, 
within  a  few  hours,  becoming  clear  on  the  defervescence  of  the  fever.  The 
disease  may  now  stop.  Or,  after  temporary  cessation,  the  hemoglobinuria, 
epigastric  distress,  and  other  symptoms  may  return  with  the  next  fever  fit. 
On  the  other  hand,  all  the  symptoms  may  persist ;  there  being  no  remission, 
the  patient  continues  feverish  and  to  pass  black -brown  urine  in  great 
abundance,  or,  it  may  be,  in  gradually  decreasing  amount.  In  the  latter 
case  the  secretion  may  be  reduced  to  a  few  ounces  of  a  dark  gummy 
material,  or  it  may  be  entirely  suppressed.  The  spleen  and  liver,  during 
the  attack  and  afterwards,  are  enlarged  and  very  tender.  A  profound 
anaemia  and  great  prostration  are  rapidly  induced. 

Death  from  this  disease  is  very  common — a  large  proportion,  equalling 
at  least  25  per  cent.,  of  the  attacks  proving  fatal.  Death  may  occur 
from  asthenia  during,  or  soon  after,  the  attack ;  from  syncope ;  from 
uraemia  consequent  on  suppression  ;  or  from  nephritis  at  a  somewhat  later 
period.  In  the  majority  of  cases  the  threatening  symptoms  clear  away 
rapidly  or  more  slowly ;  but  if  the  patient  remain  in  the  malarial  district, 
he  is  prone  to  a  recurrence  of  all  the  symptoms  during  some  subsequent 
attack  of  fever. 

The  urine  is  characteristic.  On  standing,  a  copious  deposit  forms,  which 
chemically,  with  the  polariscope,  and  under  the  microscope,  shows  all 
the  characters  of  slightly  altered  haemoglobin.  It  often  includes  many 
haemoglobin  tube  casts,  and  much  brown,  amorphous,  granular  material; 
but  there  are  no,  or  very  few,  red  blood  corpuscles.  The  urine  is  highly 
albuminous  during  the  height  of  the  attack;  and  albumin  in  gradually 
diminishing  amount  may  be  found  in  it  for  several  days  after  the  colour 
has  become  normal  and  haemoglobin  has  entirely  disappeared. 

One  attack  of  this  disease  powerfully  predisposes  to  subsequent  attacks. 
It  rarely  occurs  in  new-comers,  being  most  frequent  about  the  third  or 
fourth  year  of  residence  in  the  endemic  area.  Those  who  have  suffered  in 
the  tropics  may  have  a  relapse  after  their  return  to  Europe,  and  may  even 


MALARIA  AND  MALARIAL  DISEASE.  309 

die  of  the  same ;  it  would  seem,  however,  that  once  arrived  in  a  temperate 
climate,  the  tendency  to  attack  ceases  after  four  or  five  months.  In  the 
endemic  area,  the  slightest  chill  or  physiological  strain  is  apt  to  bring  on 
an  attack  in  the  susceptible.  The  natives  suffer  occasionally  from  haemo- 
globinuric  fever,  but  with  them  it  is  a  very  rare  occurrence. 

There  is  strong  evidence  for  believing  that  in  certain  idiosyncrasies 
quinine  is  the  most  potent  determining  cause  for  the  explosion  of  haemo- 
globinuric  attacks ;  a  special  type  of  malaria  parasite  preparing  the  blood 
for  the  cataclysm. 

It  is  believed  by  some  that  this  disease  is  of  comparatively  recent 
introduction  into  Africa,  and  that  it  is  yearly  becoming  more  common  there. 
Until  quite  recently,  it  appears  to  have  been  unknown,  at  all  events  it 
was  undescribed  in  India.  A  small  variety  of  plasmodium,  as  well  as 
benign  tertian  parasites,  have  frequently  been  found  in  the  blood,  but 
their  exact  characters,  as  yet,  have  not  been  fully  determined.  Yersin 
says  that  he  has  found  a  special  form  of  bacterium  in  the  urine,  a  bacillus 
which  he  is  inclined  to  regard  as  having  a  bearing  on  the  pathology  of 
the  disease.     This  observation  has  not  been  confirmed. 

From  clinical  and  epidemiological  considerations,  I  have  been  led  to 
regard  the  parasite  of  hsemoglobinuric  fever  as  being  in  some  respects 
different  from  that  of  ordinary  malarial  infections.  Eecently  Sambon 
suggests  that  it  is  similar  to  Pyrosoma  bigeminum,  the  parasite  giving  rise 
to  Texas  cattle  fever,  a  parasite  which  is  transmitted  through  the  cattle 
tick,  Oophilus  bovis. 

Malarial  cachexia. — In  consequence  of  severe,  or  of  prolonged,  or  of 
frequent  attacks  of  malarial  fever,  and  also  of  long  residence  in  malarious 
localities,  a  characteristic  cachexia  may  ensue.  All  malarial  attacks 
eventuate  in  more  or  less  anaemia.  In  fevers  caused  by  the  benign 
non-crescent-forming  parasites,  quartan  or  tertian,  provided  the  cases  are 
properly  treated,  the  anaemia  as  a  rule  quickly  disappears;  but  after 
infections  by  the  malignant,  small-spored^  crescent-forming  parasites,  and 
also  in  untreated  benign  infections,  a  very  definite  and  characteristic 
cachexia  of  a  more  permanent  character  is  to  be  expected. 

The  intensity  of  this  cachexia  differs  in  different  individuals.  Besides 
the  anaemia  and  its  usual  accompaniments  of  vertigo,  tinnitus,  lassitude, 
liability  to  oedema  of  the  legs,  retinal  haemorrhages,  and  so  forth,  malarial 
cachexia  is  invariably  accompanied  by  enlargement  of  the  spleen — often 
to  an  enormous  extent,  the  organ  descending  to  the  crest  of  the  ilium, 
stretching  well  to  the  right  of  the  umbilicus,  and  sometimes  almost  filling 
the  abdomen.  In  many  cases  the  liver  also  is  swollen,  but,  as  compared 
to  the  spleen,  to  a  much  smaller  extent.  Other  features  of  this  cachexia 
are  a  peculiar,  sallow,  earthy,  subicteric  colour  of  skin;  dirty  yellow 
sclerotics ;  proneness  to  ulceration  after  slight  injury — especially  of  the 
legs ;  tendency  to  a  scorbutic-like  condition  of  the  gums ;  haemorrhagic 
complications,  such  as  bleeding  from  the  gums,  nose,  bowel,  and  small 
haemorrhagic  effusions  into  the  skin,  especially  around  insect  bites ;  liability 
to  catarrhal  affections  of  the  alimentary  canal ;  irregular  attacks  of  slight 
or  severe  fever ;  and,  generally,  the  presence  of  some  form  of  the  plasmodium 
— more  especially  of  the  crescent  body — in  the  blood.  The  reproductive 
powers  are  said  to  be  very  much  impaired. 

Although  cases  are  on  record  in  which  a  mother,  reputed  to  be  the 
subject  of  malaria,  gave  birth  to  a  child  with  an  enlarged  spleen  and  other 
evidences  of  intra-uterine  malaria,  so  far  there  has  been  no  such  instance 


310  GENERAL  DISEASES. 

in  which  the  diagnosis  was  confirmed  by  a  microscopic  examination  of  the 
blood.  In  the  immature,  the  cachexia  tends  to  retard  development  and 
to  postpone  the  advent  of  puberty. 

In  recent  cases,  the  spleen,  by  suitable  treatment,  can  be  reduced  in 
size,  often  completely ;  but  in  cases  of  long  standing,  the  hypertrophy, 
depending  as  it  does  in  great  part  on  fibrous  changes  in  capsule,  trabeculse, 
and  parenchyma,  is  permanent.  In  many  malarious  districts  nearly  every 
inhabitant  is  the  subject  of  this  form  of  enlargement  of  the  spleen — 
"splenic  tumour,"  as  it  is  called.  This  fact  has  two  very  important 
practical  bearings.  First,  the  relative  frequency  of  splenic  tumours  in 
a  district  is  a  convenient  indication  of  its  salubrity,  or  the  reverse. 
Second,  these  spleens  are  readily  ruptured  by  slight  violence ;  consequently, 
in  the  natives  of  those  districts,  violent  games,  corporal  punishment,  or 
anything  which  is  likely  to  eventuate  in  a  blow  over  the  spleen,  are  to  be 
carefully  avoided. 

Malarial  cachectics  are  prone  to  attacks  of  intermitting,  quotidian,  or 
tertian  neuralgia,  especially  in  the  supra-  or  infra-orbital  nerves.  They  are 
also  liable  to  headaches,  gastralgia,  vomiting,  and  attacks  of  palpitation. 
Pneumonia  is  likewise  a  common  and  highly  dangerous  occurrence  with 
them,  and  so  are  dysentery  and  diarrhoea. 

Diagnosis. — Apart  from  such  considerations  as  history  and  locality 
suggest,  the  diagnosis  of  malarial  disease  hinges  principally  upon  four  points 
— (1)  periodicity;  (2)  enlargement  of  the  spleen;  (3)  the  action  of 
quinine  ;  (4)  the  presence  of  the  plasmodium  or  its  product — 'melanin — in 
the  peripheral  circulation.  With  the  exception  of  the  last,  none  of  these 
is  infallible  as  a  test  for  malaria.  Unfortunately,  as  affecting  the  micro- 
scopic method  of  diagnosis,  negative  results  from  an  examination  of  the 
blood,  particularly  if  made  after  the  administration  of  quinine,  are  not  of 
the  same  value  in  deciding  against,  as  positive  results  are  in  indicating, 
the  presence  of  malarial  infection. 

Periodicity,  particularly  tertian  or  quartan  periodicity,  is  a  valuable 
sign  of  malaria.  lb  must  be  remembered,  however,  as  affecting  the  diagnostic 
value  of  quotidian  periodicity,  that  most  febrile  processes,  particularly  such 
as  are  associated  with  suppuration — abscess  of  the  liver,  for  example — are 
sometimes  in  regularity  of  rhythm  remarkably  like  malarial  fever ;  so  i& 
that  fever  which  is  sometimes  associated  with  gallstones,  with  surgical 
kidney,  with  urethral  disease,  with  tuberculous  processes,  and  so  on. '  An 
intermittent  quotidian  fever  setting  in  early  in  the  day  and  having  its 
fastigium  before  late  afternoon,  is  probably  malarial ;  septic  fevers,  as  a 
rule,  have  their  fastigium  later  in  the  day  or  during  the  evening  or  night. 
Tertian  and  quartan  periodicity,  when  pronounced,  are  peculiar  to  and 
absolutely  diagnostic  of  malaria. 

Enlargement,  of  the  spleen,  if  absent,  tells  against  a  diagnosis  of 
malaria ;  but  its  presence  in  connection  with  a  recurring  or  intermittent 
fever  is  by  no  means  pathognomonic  of  malaria.  This  type  of  fever  and 
splenic  tumour  are  found  concurring  in  many  other  diseases — splenic 
leucocythaemia,  pernicious  anaemia,  Malta  fever,  for  example. 

The  action  of  quinine  in  intermittents  and  in  many  irregular  malarial 
fevers  is  usually  so  prompt  and  decided,  that  it  supplies  one  of  the  most 
valuable  tests  of  malaria  we  possess.  In  remittents,  however,  its  action  is 
not  generally  so  marked  or  prompt.  In  pernicious  attacks  it  is  of  little 
practical  value  as  a  diagnostic,  seeing  that  diagnosis  in  these  cases,  to  be 
of  use,  must  be  made  at  once  and  before  quinine  could  have  time  to  act. 


MALARIA  AND  MALARIAL  DISEASE.  311 

In  haemoglobinuric  fever,  quinine,  whether  from  the  standpoint  of  diagnosis 
or  of  treatment,  seems  to  have  little  or  doubtful  value. 

Presence  of  the  Plasmodium. — By  far  the  most  valuable  indication  of 
malarial  disease  is  the  discovery  of  plasmodia  or  their  product,  melanin,  in 
the  blood.  A  microscopical  examination  of  the  blood  should  therefore  be 
made  in  every  case  in  which  the  slightest  doubt  exists ;  if  possible,  it  should 
be  made  before  quinine  is  administered,  as  this  drug  causes  most  of  the 
forms  of  the  plasmodium — all,  in  fact,  except  the  crescent  body  and  its 
derivatives — to  disappear  rapidly  from  the  circulation.  Fresh  wet  pre- 
parations should  be  examined  first ;  if  the  result  from  these  is  negative, 
and  for  greater  security,  stained  preparations  should  then  be  examined. 

The  following  procedures  are  well  adapted  for  demonstrating  the 
Plasmodium.  Cleanse  very  thoroughly  several  slips  and  cover-glasses  with 
alcohol ;  cleanse  a  finger-tip  in  the  same  thorough  way.  Prick  the  finger 
with  a  clean  needle.  Express  from  the  puncture  a  small  quantity  of 
blood  ;  this,  as  it  may  contain  epithelium  detached  by  the  needle,  should 
be  wiped  away  with  a  clean  cloth.  Express  from  the  same  puncture  a 
second  droplet,  about  as  large  as  a  pin's  head ;  touch  the  apex  of  this 
lightly  (taking  care  not  to  impinge  on  the  skin)  with  the  centre  of  a  cover- 
glass,  and  lay  the  cover-glass  on  a  slip.  If  glasses  and  finger  are  clean, 
the  blood  will  at  once  run  out  in  an  exceedingly  delicate  film  in  a  con- 
siderable area,  of  which  the  corpuscles  lie  flat,  isolated,  and  slightly 
expressed.  After  waiting  about  a  minute  for  the  blood  film  to  spread 
out,  it  is  well  to  ring  the  cover-glass  with  vaseline,  to  prevent  evaporation 
and  consequent  crenation,  movement,  and  excessive  compression  of  cor- 
puscles. Using  a  twelfth  of  an  inch  immersion  objective,  and  a  good  but 
not  too  brilliant  illumination,  search  is  made  in  those  parts  of  the  film  in 
which  the  blood  corpuscles  are  lying  isolated  and  flat.  Each  corpuscle  is 
separately  scrutinised,  the  observer  looking  carefully  for  any  indication 
of  black  pigment,  or  of  a  pale,  nebulous,  amoeboid  body  lying  in  the  haemo- 
globin. There  is  little  difficulty  in  recognising  the  larger  forms  of  the 
highly  pigmented  intracorpuscular  bodies,  the  rosette  bodies,  the  crescents, 
the  crescent-derived  spheres,  and  the  flagellates  ;  but  it  is  sometimes  very 
difficult,  at  all  events  for  the  novice,  to  recognise  the  smaller  and  un- 
pigmented  phases  of  the  plasmodium.  When  doubt  exists  about  some 
intracorpuscular  appearance,  the  detection  of  amoeboid  movement  is  a 
valuable  aid.  Vacuoles  must  not  be  mistaken  for  plasmodia ;  the  former 
are  clear,  sharp  in  outline,  and  non-amceboid,  and  of  course  do  not  take  a 
stain ;  the  latter  are  nebulous,  with  ill-defined  outlines,  often  amoeboid,  and 
readily  take  the  methylene-blue  stain  after  fixing  with  alcohol  or  heat. 
Certain  of  the  minute  plasmodia  tend  to  assume  a  ring  form,  which  is  very 
characteristic ;  although  minute,  these  rings  are  clear,  well  defined,  and 
not  difficult  to  recognise.  They  are  sometimes  seen  in  very  dark,  shrivelled 
corpuscles,  called  from  their  colour  "  brassy  bodies  " ;  such  are  frequent  in 
malignant  infections.  Pigmented  leucocytes  are  easily  made  out,  and  are 
quite  as  pathognomonic  of  malaria  as  the  actual  plasmodium  itself.  In 
seeking  for  plasmodia,  the  novice  must  bear  in  mind  that  rosette  bodies 
and  fi/igollatcs  are  not  always,  or  even  generally,  present ;  in  fact,  they  are 
only  to  be  found  at  particular  times  in  the  case  of  the  former,  and  only 
some  time  after  the  slide  has  been  put  up  in  the  case  of  the  latter.  The 
usual  forms  encountered  are  the  smaller  or  larger  unpigmented  or  pig- 
mented intracorpuscular  phases,  crescents,  and  crescent-derived  ovals  and 
spheres.    To  find  flagellates,  it  is  best  to  select  a  crescent  case,  and,  as  Eoss 


3i2  GENERAL  DISEASES 

has  pointed  out,  to  expose  the  droplet  of  blood  to  the  air  for  two  or  three 
minutes  before  making  the  preparation ;  if  the  slide  be  examined  from 
fifteen  to  twenty  minutes  later,  and  the  crescents  have  been  present,  a 
considerable  proportion  of  them  will  now  be  found  transformed  into 
flagellates. 

In  those  parts  of  the  preparation  in  which,  from  compression,  the  blood 
corpuscles  have  been  ruptured,  fragmented  plasmodia,  or  even  entire 
Plasmodia,  are  often  seen  free  in  the  liquor  sanguinis.  These  bodies  are 
generally  spherical  or  discoid,  and  contain  innumerable  particles  of 
fragmented  melanin  dust,  or  protoplasmic  granules  in  active  Brownian 
movement. 

To  prepare  stained  films,  the  following  plan  will  be  found  serviceable. 
Provide  a  piece  of  tissue  paper,  or,  better,  of  guttapercha  tissue  2  in.  long 
by  1  in.  broad.  Prick  the  finger  and  express  a  droplet  of  blood  in  the 
usual  way.  Take  the  blood  up  on  one  face  of  the  guttapercha  tissue, 
near  one  end.  Lay  the  tissue  on  a  slip,  and,  after  pausing  for  a  few  seconds 
to  allow  the  blood  to  run  out  in  a  film  between  it  and  the  slip,  draw  the 
former  horizontally  along  the  slip ;  a  very  fine  and  often  beautifully 
uniform  film  is  the  result.  This,  after  it  has  dried,  is  fixed  by  pouring 
on  it  a  few  drops  of  absolute  alcohol ;  five  minutes  suffice.  It  is  then 
dried  again,  and  the  stain— 2  per  cent,  methylene-blue,  5  per  cent,  borax 
in  distilled  water — is  dropped  on  the  film.  After  thirty  or  forty  seconds 
the  preparation  is  thoroughly  washed,  dried,  and  mounted  in  zylol  balsam. 
The  microscopical  examination  should  be  made  with  a  twelfth  of  an  inch 
immersion  lens.  The  parasites  (Fig.  39)  are  readily  recognised  by  their 
blue  tint ;  by  the  fact  that  they  are  lying  in  red  blood  corpuscles ;  by  the 
presence  of  black  pigment  in  the  interior  of  the  larger  plasmodia  ;  and,  in 
the  case  of  most  of  the  immature  plasmodia,  by  the  large,  unstained,  and 
very  apparent  vesicular  nucleus,  usually  containing  a  minute,  deeply 
stained,  and  eccentrically  placed  nucleolus.  The  smaller  parasites  appear 
in  such  preparations  as  minute,  delicate,  blue  rings  surrounding  the  un- 
stained vesicular  nucleus,  which  almost  invariably  carries  a  very  apparent, 
deeply  stained,  eccentrically-placed  nucleolus.  Crescents  and  sporulating 
forms  are  easily  recognised.  There  should  be  no  difficulty  in  distinguishing 
the  plasmodium  from  the  leucocyte,  as  the  nuclei  of  the  leucocytes  are 
deeply  stained,  whilst  those  of  the  parasite  are  unstained ;  the  former  have 
no  setting  of  haemoglobin ;  moreover,  the  peripheral  protoplasm  of  the 
parasites,  though  less  deeply  stained  than  the  nuclei,  is  more  deeply 
stained  than  the  protoplasm  of  the  leucocytes. 

There  are  many  other  methods  of  staining  malarial  parasites,  but  none 
so  easy  of  application,  or  which  give  better  results,  than  those  processes 
in  which  methylene-blue  is  the  staining  agent.  Eosin  or  safranin  may 
be  used  as  counter-stains.     They  are  not  necessary. 

To  stain  the  flagellated  bodies,  I  recommend  the  following : — Select  a 
case  in  which  crescents  are  numerous.  Prepare  a  moist  chamber  by  cutting 
an  oblong  hole  in  a  piece  of  thick  blotting-paper,  which  is  then  moistened 
and  laid  on  some  non-absorbent  flat  surface.  Take  a  small  droplet  of  blood 
upon  the  centre  of  a  slip,  and  spread  it  out  quickly  with  a  needle.  Imme- 
diately place  the  slip  over  the  moist  chamber.  After  half  to  three-quarters 
of  an  hour,  remove  the  slide ;  dry  it  quickly ;  fix  with  alcohol ;  remove 
haemoglobin  by  immersing  for  half  an  hour  in  weak  (20  per  cent.)  acetic 
acid;  wash  well;  stain  for  six  hours  in  30  per  cent,  carbol-fuchsin  ;  wash; 
mount  in  xylol.     Beautiful  preparations  may  be  obtained  in  this  way. 


MALARIA  AND  MALARIAL  DISEASE.  313 

It  must  never  be  forgotten  that  malarial  fever  is  prone  to  complicate 
other  diseases,  such  as  enteric  fever,  phthisis,  the  various  forms  of  anaemia, 
dysentery,  and  so  forth.  Under  such  circumstances  a  microscopical  examina- 
tion of  the  blood  is  invaluable. 

Prognosis. — Although  the  mortality  from  malarial  disease  as  com- 
pared to  the  number  of  attacks  is  small,  yet,  on  account  of  the  great 
frequency  of  this  infection,  the  aggregate  mortality  is  very  large  indeed. 
In  India,  for  example,  the  deaths  from  malaria  far  exceed  those  from 
cholera  or  any  other  disease.  Ordinary  uncomplicated  intermittents  or 
remittents,  as  immediately  affecting  life,  are  of  little  gravity ;  but  as  they 
are  always  followed  by  more  or  less  anaemia,  and  are  nearly  certain  to 
recur,  they  generally  give  rise  to  much  debility  and  very  frequently  to 
various  abdominal  or  other  complications.  In  this  way,  doubtless,  they 
predispose  to  other  disease,  and  are  a  fruitful  indirect  cause  of  death. 

The  prognosis  depends  in  great  measure  on  the  treatment  employed 
and  the  hygienic  conditions  of  the  patient.  Liberal  but  judicious  dosing 
with  quinine,  good  food,  and  change  to  a  salubrious  district,  usually  mean 
speedy  recovery ;  no  quinine,  indifferent  food,  and  continued  residence  in  a 
malarial  district,  mean  relapse,  and  sooner  or  later  forms  of  malarial 
cachexia. 

Pernicious  attacks  are  always  dangerous,  particularly  if  not  promptly 
recognised  and  properly  treated.  The  mortality  in  such  attacks  amounts 
to  about  one  in  three.  Infections  of  the  small  crescent-forming  parasite 
are  much  more  dangerous  than  those  from  the  benign  tertian  or  from  the 
quartan  plasmodia.  They  are  also  more  prone  to  recur,  more  often 
followed  by  cachexia,  more  liable  to  assume  pernicious  characters,  and 
are  less  amenable  to  quinine.  Because  the  smaller  type  of  parasite 
prevails  especially  in  autumn,  and  the  benign  parasite  more  particularly  in 
the  earlier  part  of  the  year,  autumn  malaria  is  usually  more  serious  than 
spring  attacks.  Great  differences  are  observable  in  malaria  according  to 
the  locality  in  which  it  is  acquired ;  thus  West  African  malaria,  as  a  rule, 
is  infinitely  more  dangerous  than  the  malaria  of  Europe  or  even  of  India. 

Treatment. — The  treatment  of  malarial  disease  means  the  admini- 
stration of  quinine.  For  ordinary  cases  I  make  it  a  practice  to  give 
10  grs.  of  the  sulphate  so  soon  as  the  sweating  stage  is  well  established, 
and  thereafter  5  grs.  three  times  a  day  for  three  or  four  days.  The 
drug  is  said  to  act  most  effectively  on  the  young  forms  of  the  plasmodium, 
and  it  is  these  forms  that  predominate,  or  are  perhaps  the  only  form 
present,  during  the  sweating  stage.  With  a  view  to  prevent  relapse, 
I  generally  recommend  that  three  5-gr.  doses  be  taken  one  day  each 
week — that  is,  every  seventh  day — during  from  six  consecutive  weeks  to 
three  months,  a  mild  saline  purgative  being  administered  in  the  early 
morning  of  the  same  day.  Agues  rarely  resist  this  treatment.  Although 
quinine  acts  most  efficiently  when  given  shortly  before  the  commencement 
of  the  paroxysm,  unless  in  the  presence  of  threatened  danger  it  is  not 
advisable  to  give  it  at  that  time  or  during  the  cold  or  hot  stages; 
given  then  it  is  apt  to  aggravate  headache,  and  it  has  no  influence  in 
cutting  short  the  impending  or  current  attack.  But  in  continued  fevers, 
or  in  the  presence  of  danger,  quinine  should  be  given  at  once  in  10-gr. 
doses  every  six  hours  or  oftener,  and  irrespective  of  the  stage  of  the 
disease 

In  agues,  quinine,  when  efficiently  administered,  very  often  stops  or 
powerfully  modifies  the  following  attack;    almost  invariably  the  second 


314  GENERAL  DISEASES. 

following  attack  does  not  come  on.  When  the  stomach  is  irritable  and 
there  is  much  vomiting,  and  when  such  a  case  is  not  deemed  grave,  quinine 
may  be  given  in  enema.  The  dose  in  this  case  should  be  double  of  that 
given  by  the  mouth.  Before  administering  it,  the  bowel  must  be  washed 
out  by  a  simple  enema.  In  serious  fevers,  and  when  the  tongue  is  foul, 
and  there  are  evidences  of  gastric  catarrh  and  debilitated  digestion,  the 
drug  should  be  given  in  solution.  When  the  tongue  is  clean,  freshly  made 
quinine  pill,  or  the  powder  in  cachet,  tabloid,  or  milk,  are  less  unpleasant 
to  take,  and  are  absorbed  readily  enough. 

Important  accessories  to  treatment  by  quinine  are  rest,  warmth,  and 
good  food.  These  alone  sometimes  suffice  to  bring  about  the  cessation, 
for  the  time  being  at  all  events,  of  the  active  manifestations  of  malaria. 
I  have  often  watched  the  gradual  disappearance  of  the  plasmodium  from 
the  blood,  and  of  the  associated  recurring  febrile  attacks,  under  their  influ- 
ence alone,  and  without  a  grain  of  quinine  having  been  swallowed. 

In  the  presence  of  severe  malarial  attacks  attended  with  vomiting,  and 
particularly  when  a  pernicious  attack  is  impending,  or  has  developed,  the 
quinine  must  be  given  hypodermically  and  in  full  and  repeated  doses. 
Owing  to  its  great  solubility  in  water,  and  to  its  containing  more  of  the 
alkaloid  than  the  sulphate,  the  acid  hydrochlorate  is  the  best  salt  for 
hypodermic  injection.  The  following  is  a  good  solution  for  hypodermic 
purposes: — Acid  hydrochlorate  of  quinine,  5  grms. ;  distilled  water,  10  c.c. 
Of  this  1  c.c.  is  equal  to  J  grm. — 7|  grs. — of  the  salt — a  sufficient  dose 
in  ordinary  cases,  but  which  in  severe  or  in  pernicious  cases  has  to  be 
doubled  and  administered  at  least  thrice  a  day.  In  the  absence  of  the 
acid  hydrochlorate  the  ordinary  commercial  hydrochlorate  can  be  used,  a 
little  hydrochloric  acid,  or  one-fourth  part  of  its  weight  of  antipyrine, 
being*  added  to  aid  solution.  The  latter  injection  is  said  to  give  good 
results.  Sometimes  neither  of  the  hydrochlorates  are  procurable ;  in  that 
case  the  sulphate  must  be  employed,  solution  being  effected  by  the  addition 
of  half  its  weight  of  tartaric  acid.  In  using  hypodermic  injections  of 
quinine,  great  care  must  be  exercised  to  secure  a  perfectly  aseptic  condi- 
tion of  the  instruments,  the  solution,  and  the  skin.  The  instrument  and 
solution  should  be  boiled ;  only  a  filtered  and  clear  solution  should  be  used ; 
and  the  skin  must  be  thoroughly  cleansed.  The  injection  should  be  made 
deep  into  the  subcutaneous  tissue  and  not  into  the  derma,  the  eye  of  the 
needle  being  directed  away  from  the  skin.  Some  prefer  to  inject  deep 
into  the  body  of  a  muscle  to  injecting  close  under  the  skin ;  it  is  much 
less  painful.  Abscess,  ulcers,  and  ugly  scars  have  sometimes  resulted ;  and 
more  than  once  lives  have  been  lost  from  tetanus  after  quinine  injections. 
Such  mishaps  are  almost  entirely  attributable  to  the  use  of  dirty  syringes 
and  solutions. 

Baccelli,  in  certain  malignant  and  almost  desperate  cases  of  malaria, 
has  employed  successfully  intravenous  injections  of  quinine.  His  pre- 
scription is: — Hydrochlorate  of  quinine,  1  grm.;  chloride  of  sodium,  75 
cgrms. ;  distilled  water,  10  grms.  By  means  of  a  Pravaz  syringe,  half  of 
this  quantity,  slightly  warmed,  is  injected  into  a  vein.  The  needle  should 
be  thrust  well  into  the  distended  vein,  and  injection  made  in  the  direction  of 
the  circulation. 

In  severe  remittents,  in  continued  malarial  fevers,  and  in  pernicious 
attacks,  besides  administering  quinine,  which  is  invariably  the  first  and 
most  important  duty  to  be  attended  to,  certain  symptoms  may  require 
special  treatment.    In  bilious  remittents  attended  with  excessive  vomiting, 


MALARIA  AND  MALARIAL  DISEASE.  315 

sinapisms  to  the  epigastrium,  a  full  dose  of  calomel  or  sometimes  of  ipecacu- 
anha, and  afterwards,  if  necessary,  a  small  hypodermic  injection  of  morphine, 
are  often  effective  in  allaying  sickness ;  effervescing  drinks  or  sips  of  very 
hot  water  are  also  useful  in  these  circumstances.  In  pernicious  attacks  of 
an  algid  character,  frictions  with  camphor  and  spirit ;  ether  or  strychnine 
by  the  mouth  or  hypodermically ;  hot  bottles  to  the  extremities ;  cham- 
pagne, and  other  alcoholic  stimulants,  are  all  sometimes  of  service  in 
stimulating  the  circulation  and  procuring  reaction.  In  hyperpyrexia,  efforts 
to  reduce  and  keep  down  temperature  must  be  prompt  and  energetic ;  cold 
sponging,  ice  to  the  head,  iced  enemata,  or,  better,  continuous  immersion 
in  a  cool  bath,  the  temperature  of  which  is  gradually  lowered  and  regulated 
by  ice  or  cold  water,  are  indispensable.  Pending  the  specific  action  of 
hypodermic  injections  of  quinine  in  10-gr.  doses,  repeated  hourly  for 
two  or  three  .  times  if  necessary,  it  is  imperative  to  lower  and  keep  down 
temperature,  otherwise  the  patient  will  surely  die.  Ordinary  antipyretics, 
such  as  antipyrine,  phenacetin,  etc.,  are  useless  or  even  dangerous  in  per- 
nicious attacks,  although  they  are  of  distinct  service  in  relieving  headache 
in  the  milder  malarial  fevers. 

The  most  opposite  opinions  are  entertained  in  regard  to  the  treatment 
of  htemoglobinuric  fever.  Some  advocate  quinine  in  full  doses,  20  to  30 
grs.  repeated  two  or  three  times  a  day ;  some  recommend  it  in  moderate 
doses,  5  to  10  grs. ;  others,  again,  have  discarded  this  drug  altogether, 
in  the  belief  that  it  aggravates  the  hemoglobinuria.  Calomel  in  large 
doses  is  much  in  vogue  for  this  type  of  malaria  in  Africa.  Certain  French 
writers  have  lately  advocated  chloroform — 5  to  6  minims  in  water  every 
ten  minutes,  till  a  certain  degree  of  chloroform  intoxication  is  produced, 
the  effect  being  subsequently  kept  up  by  chloral.  Tannin  has  also  a 
certain  reputation  in  haemoglobinuric  fever,  as  well  as  in  other  forms  of 
malaria  ;  it  is  given  in  15-gr.  doses,  in  sweetened  water,  every  eight  hours. 
The  subject  of  one  attack  of  hsemoglobinuric  fever  should,  if  at  all  possible, 
quit  the  endemic  area,  otherwise  relapse  on  the  slightest  exposure  or 
strain  is  almost  certain,  and  then  the  risk  to  life  is  very  great.  Such 
patients,  however,  must  be  careful  to  avoid  returning  to  Europe  in  the 
late  autumn,  winter,  or  early  spring,  for  it  often  happens  that  a  sudden 
and  premature  plunge  into  cold  weather  provokes  an  attack  which  may 
prove  fatal ;  such  patients  should  winter  at  the  Canaries  or  in  Egypt. 

For  the  anaemia  succeeding  malarial  attacks,  arsenic  combined  with 
iron  and  small  doses  of  quinine  or  nux  vomica  is  the  best  remedy.  It  must 
be  supplemented  by  good  food,  a  little  generous  wine,  warm  clothing,  and, 
if  possible,  a  dry,  sunny,  and  not  too  cold  a  climate.  Mountain  air  or  a  sea 
voyage  are  excellent  restoratives. 

For  the  congestions  of  liver  and  spleen,  and  the  chronic  intestinal 
catarrhs — so  common  a  sequela  of  malaria — there  is  nothing  more  effica- 
cious than  a  course  of  Carlsbad.  If  it  is  impossible  to  visit  Carlsbad,  a  fair 
substitute  for  the  waters  and  the  treatment  practised  there  is  as  follows : — ■ 
Dissolve  53  grs.  of  Carlsbad  salt  in  a  pint  of  very  hot  water ;  divide  this 
into  three  equal  portions ;  the  three  portions  are  sipped  hot  and  slowly,  at 
intervals  of  twenty  minutes,  the  first  thing  every  morning  and  on  an  empty 
stomach.  Food  must  be  light  and  digestible ;  milk,  fat,  cheese,  fruit,  wine 
and  beer,  and  all  indigestibles  being  avoided.  The  course  should  be  kept 
up  for  three  weeks. 

If  enlargement  of  the  spleen  persist  after  a  malarial  attack,  it  may  be 
treated  by  counter-irritation  with  liniment  of  iodine,  and  with  mild  warm 


3i6  GENERAL  DISEASES. 

saline  aperients  and  quinine.  Arsenic  and  iron,  electricity,  carefully 
applied  hot  and  cold  water  douches,  and  gentle  massage  are  all  useful  at 
times.  Whenever  practicable,  the  subject  of  repeated  malarial  fevers  should 
leave  the  endemic  district,  and,  if  possible,  return  for  a  time  to  Europe. 

Many  substitutes  for  quinine  have  been  suggested  and  tried.  Amongst 
others  may  be  mentioned  arsenic  in  very  large  doses,  strychnine,  chiretta, 
iodine,  alum,  tannin,  methylene-blue,  anarcotin,  phenocol,  analgen,  carbolic 
acid,  etc.  None  of  these,  however,  approach  quinine  in  efficacy.  "What  is 
known  as  Warburg's  tincture,  and  which  contains  a  large  number  of 
diaphoretic  drugs,  and  also  a  considerable  quantity  of  quinine,  is  much 
used  in  Indian  practice.  The  dose  is  half  an  ounce,  to  be  repeated  at  the 
end  of  two  or  three  hours.  Warburg's  tincture  generally  brings  on  profuse 
diaphoresis.  It  has  sometimes  succeeded  where  quinine  alone  had  failed 
apparently.  This  must  be  based  on  the  fact  that  the  mosquito  is  the 
transmitting  agent  of  the  malarial  parasite. 

Prophylaxis. — Much  can  be  and  has  been  done  by  efficient  drainage 
and  careful  cultivation  to  extirpate  mosquitoes,  and  so  to  render  malarious 
countries  healthy ;  unfortunately,  much  has  also  been  done  by  the  artificial 
irrigation  of  previously  dry  and  healthy  countries  to  render  them  malarious. 
As  an  example  of  the  former,  the  case  of  the  fen  country  in  England 
may  be  quoted ;  of  the  latter,  the  unhealthiness  which  has  succeeded 
irrigation  works  in  many  parts  of  India. 

The  sites  of  dwelling-houses  in  malarious  districts  should  always  be 
carefully  selected,  rising  ground  being  preferred  to  a  valley.  Dwelling- 
rooms,  especially  bedrooms,  should  be  well  raised  above  the  ground. 
Mosquito  nets  are  indispensable.  The  neighbourhood  of  the  residence 
should  be  drained  and  covered  with  well-kept  turf,  or  cultivated.  All 
puddles  should  be  filled  in  with  earth,  or  drained,  or  kept  covered  with  a 
film  of  kerosene  oil,  a  few  ounces  of  which  quickly  rid  a  pool  or  pond  of  its 
mosquitoes.  Districts  in  which  many  of  the  inhabitants  have  enlarged 
spleens  must  be  avoided  as  places  of  residence.  If  there  be  an  option,  a 
town  residence,  after  the  town  has  been  built  for  several  years,  is  decidedly 
preferable  to  a  suburban  or  country  one ;  but  during  the  building  of  a 
town,  and  for  some  years  afterwards,  the  open  country  is  the  safer. 
Journeys  and  campaigns  in  malarious  districts  ought  not  to  be  undertaken 
during  the  fever  season. 

There  has  been  considerable  difference  of  opinion  with  regard  to  the 
prophylactic  virtues  of  quinine.  General  experience,  however,  is  now 
decidedly  in  favour  of  its  systematic  use  with  this  object— at  all  events, 
during  journeys  or  temporary  residence  in  malarious  countries.  Three  to 
five  grs.  once  a  day,  or  two  or  three  5-gr.  doses  in  one  day  once  or  twice 
a  week,  may  be  taken.     Arsenic  is  of  no  value  as  a  prophylactic. 

In  malarial  countries,  great  care  should  be  exercised  to  preserve  the 
general  health.  Eegular  exercise;  temperance  in  eating  and  drinking; 
sufficient  but  not  exhausting  occupation ;  cheerfulness ;  the  avoidance  of 
chill,  of  constipation,  of  exposure  to  the  hot  sun  and  of  late  hours,  of 
mosquito  bites,  of  being  out  of  doors  before  sunrise  or  after  sunset, — these 
common-sense  matters  ought  to  be  rules  with  all  residents  in  such  districts. 

Earth-cutting  operations  are  particularly  dangerous,  and  should  be 
avoided  during  the  fever  season ;  those  employed  ought  never  to  sleep  in 
the  neighbourhood  of  such  works. 

PATRICK  MAXSON. 


GENERAL  GONORRHEAL  INFECTION.  317 


GENEKAL  GONOKKHCEAL  INFECTION. 

Besides  the  direct  extension  of  the  gonorrheal  process  to  the  adjacent 
tissues,  serious  complications,  such  as  cystitis  and  pyelitis,  may  arise 
by  continuity ;  while  in  women,  metritis,  salpingitis,  ovaritis,  and  peri- 
tonitis have  also  been  found.  In  addition  to  such  effects,  a  general 
infection  of  the  system  may  take  place,  and  produce  widespread  effects. 

Etiology. — The  gonococcus  has  been  found  in  the  blood  and  in  the  j 
internal  organs,  sometimes  alone  and  at  other  times  associated  in  a  mixed ' 
infection  with  streptococci  and  staphylococci.     The  source  of  the  infection 
is  not  always  the  urinary  tract,  since  it  has  been  found  to  take  place  as  a 
sequel  to  gonorrheal  conjunctivitis. 

Morbid  anatomy. — Where  general  systemic  infection  has  occurred, 
there  is  commonly  one  definite  seat  of  suppuration,  e.g.  an  abscess  in  some 
part  of  the  urinary  tract  or  its  annexa.  The  pathological  results  depend 
on  the  distribution  of  the  disease.  In  gonorrheal  synovitis  there  is 
effusion  into  the  affected  joint;  this  is  rarely  purulent,  but  contains 
gonococci,  often  yielding  a  pure  culture.  There  is  often  considerable  peri- 
articular inflammation,  and  the  sheaths  of  the  tendons  in  the  neighbourhood 
may  be  implicated.  When  gonorrheal  endocarditis  and  pericarditis 
have  been  set  up,  the  characteristic  lesions  are  found  after  death,  often 
associated  with  changes  in  the  muscular  wall  of  the  heart,  and  the 
gonococci  are  found  alone  or  combined  with  other  organisms. 

Symptoms. — As  the  result  of  general  infection,  a  condition  of 
profound  toxaemia  has  been  found,  and  the  patient,  as  in  a  case  narrated 
by  Osier,  passes  rapidly  into  a  typhoid  state,  and  dies,  apparently  from 
general  sepsis. 

The  most  usual  clinical  condition  is  gonorrheal  synovitis.  It  is  almost 
always  met  with  in  males,  and  only  rarely  in  females.  Usually  one  joint, 
the  knee  or  ankle,  is  first  involved,  but  others  may  be  involved  in  suc- 
cession. Certain  joints,  which  are  seldom  affected  by  rheumatism,  are 
fairly  frequently  the  seat  of  gonorrheal  infection,  namely,  the  sterno- 
clavicular, the  temporo-maxillary,  the  intervertebral,  and  the  sacro-iliac 
joints.  The  actual  amount  of  effusion  into  a  joint  is  not  great  as  a  rule, 
but  a  good  deal  of  edema  occurs  around  the  joint,  and  some  effusion  into 
the  adjacent  tendon  sheaths.  The  joints  are  extremely  tender  on  pressure, 
and  the  synovitis  is  apt  to  persist  for  some  time.  Probably,  on  account  of 
the  slow  recovery,  there  is  a  tendency  to  the  formation  of  fibrous  adhesions  ; 
and  if  repeated  attacks  occur  in  the  same  joints  from  fresh  gonorrheal 
infections,  fibrous  ankylosis  may  result.  The  ankylosis,  as  in  a  terrible 
instance  mentioned  by  Fagge,  may  affect  every  joint  in  the  body. 

In  gonorrheal  endocarditis  the  symptoms  are  those  of  a  septic  condi- 
tion, and  physical  examination  may  or  may  not  reveal  the  cardiac  mischief. 
The  course  of  this  complication  is  that  of  acute  endocarditis,  sometimes 
presenting  the  typhoid  type,  and  in  other  cases  the  intermittent.  When 
gonorrheal  pericarditis  sets  in,  it  gives  the  clinical  features  of  that  affection. 

Diagnosis. — Synovitis  occurs  as  a  symptom  of  or  a  complication  or 
sequela  of  many  diseases.  Its  association  with  rheumatism,  rheumatoid 
arthritis,  and  gout  will  be  fully  dealt  with  in  the  sequel.  It  is  very  apt  to 
follow  injury  of  almost  any  kind  to  a  joint ;  it  is  very  frequently  secondary 
to  a  general  tuberculosis,  and  is  then  the  result  of  a  tuberculous  affection  of 
the  synovial  membrane  ;  it  is  an  occasional  sequela  or  complication  of  the 


3*8 


GENERAL  DISEASES. 


various  infectious  fevers,  of  dysentery,  and  of  pysemia;  it  is  associated 
with  syphilis,  especially  in  its  later  stages ;  and  a  special  form  of  synovitis 
may  occur  in  connection  with  locomotor  ataxy,  chronic  disease  of  the  spine, 
and  occasionally  with  acute  myelitis.  All  these  possibilities  have  to  be 
borne  in  mind  before  forming  a  diagnosis.  The  different  infections  leading 
to  cardiac  complications  must  also  be  considered  in  dealing  with  endo- 
cardial affections.  The  history  of  the  case,  and  its  intractability  to  ordinary 
means  of  treatment,  may  also  be  of  diagnostic  import. 

Prognosis. — It  is  scarcely  possible  to  formulate  definite  statements 
with  regard  to  this  aspect  of  the  subject.  In  simple  arthritic  compli- 
cations the  prospect  for  the  patient  is  favourable  in  the  main,  although  the 
duration  of  the  disease  may  be  prolonged.  When  cardiac  complications 
supervene,  the  prognosis  is  very  grave. 

Treatment.  —  Salicylates  are  of  no  use  in  the  treatment  of 
gonorrheal  synovitis.  Best  should  be  enjoined,  and  cold  applications 
to  the  joints  will  effect  some  relief  of  the  pain,  but  probably  greater  relief 
is  obtained  by  the  use  of  radiant  heat  or  superheated  air.  Iodide  of 
potassium,  in  combination  with  iron  and  quinine,  should  be  given  internally. 
Suitable  treatment  for  the  gonorrhoea!  discharge  must  necessarily  be  em- 
ployed. If  the  arthritic  trouble  is  slow  to  subside,  incision  and  irrigation  of 
the  affected  joints  may  be  necessary.  When  ankylosis  takes  place,  the 
adhesions  must  be  broken  down  under  an  anaesthetic.  For  gonorrhceal 
endocarditis  the  treatment  applicable  to  endocarditis  must  be  employed. 
Probably,  in  the  near  future,  remedies  which  are  distinctly  antidotal  will 
be  found. 

A.   P.   LUFF. 


SYPHILIS. 

Syphilis  is  an  infective,  specific  disease,  of  slow  evolution  and  long 
duration ;  either  acquired  by  inoculation,  or  inherited  from  a  parent 
affected  by  the  same  malady.  The  acquired  form  is  characterised  by  a 
primary  lesion,  followed,  after  an  interval,  by  constitutional  symptoms, 
along  with  affections  of  the  skin  and  mucous  membranes,  and  commonly 
at  a  still  later  period  by  disorders  of  the  viscera,  bones,  blood  vessels,  skin, 
etc.  The  inherited  form  exhibits  similar  symptoms,  with  the  exception 
of  the  primary  lesion.  The  disease,  as  a  rule,  cannot  be  re-inoculated 
on  a  person  who  has  once  been  infected. 

History.  — Syphilis  has  probably  existed  in  its  present  form  from  the 
earliest  times,  but  it  was  not  until  about  the  end  of  the  fifteenth  century, 
when  it  appeared  in  Southern  Italy  in  an  epidemic  form,  that  it  was  recog- 
nised as  a  distinct  disease.  It  was  at  that  time  erroneously  thought  to 
be  a  new  disease  which  had  been  introduced  from  America,  then  just 
discovered.  For  long,  syphilis  was  confused  with  other  forms  of  venereal 
disease,  such  as  gonorrhoea  and  soft  chancre;  and  it  was  not  until  the 
nineteenth  century  that  it  was  completely  dissociated  from  these  maladies. 

Etiology. — Although  a  specific  micro-organism  has  not  been  dis- 
covered in  syphilitic  lesions,  there  is  little  doubt  that  the  disease  depends, 
like  tuberculosis,  on  some  parasitic  microbe.  Lustgarten  (1884)  described 
a  bacillus  which  he  found  in  sections  of  tissues  involved  in  syphilomata 
and  in  the  pus  from  hard  chancres.  It  was  3-5  fi  to  4-5  /m  in  length,  and 
resembled   the   tubercle   bacillus   in   appearance    and    staining   reaction. 


SYPHILIS.  319 

This  bacillus  seems  to  be  identical  with  the  smegma  bacillus,  so  fre- 
quently present  in  the  secretion  of  the  prepuce  or  vulva.  There  is  no 
satisfactory  experimental  evidence  that  Lustgarten's  bacillus  has  any 
causal  relation  with  the  disease.  The  same  may  be  said  of  the  bacillus 
described  by  Eve  and  Lingard  (1886),  the  micrococci  of  Disse  and  Taguchi 
(1886),  and  the  bacillus  of  Golasz  (1894).  Van  Neissen  (1899)  claims 
to  have  obtained  and  cultivated  a  bacillus  similar  to  that  of  Lustgarten. 

Syphilis  appears  to  be  a  disease  peculiar  to  the  human  race.  In  the 
human  subject  the  disorder  is  inoculable  at  all  ages,  the  only  protective 
influence  being  a  previous  successful  inoculation,  but  attempts  at  inocu- 
lation have  hitherto  always  failed  in  the  case  of  the  lower  animals. 
In  this  the  malady  differs  entirely  from  tuberculosis.  The  field  for 
experimental  research  is  therefore  very  limited.  Eecently,  Yan  Neissen 
states  that  he  has  succeeded  in  producing  hard  sores  and  gummata  in  various 
animals,  by  inoculating  with  cultures  of  the  syphilis  bacillus  he  claims 
to  have  discovered.  This,  however,  requires  corroboration.  Various  other 
experimenters  have  claimed  that  they  have  successfully  inoculated  animals, 
but  it  is  probable  that  either  matter  from  soft  chancres  or  tuberculous 
matter  was  used.  E.  Duplan  obtained  negative  results  in  sixty-eight 
inoculations,  while  in  the  case  of  two  rabbits  he  probably  inoculated 
tubercle,  not  syphilis.  Eavenel  (April  1900)  has  recorded  the  failure  of 
his  attempt  to  transmit  syphilis  to  calves. 

Modes  of  infection. — These  are  direct  and  mediate  infection,  and 
hereditary  transmission.  In  a  large  number  of  cases,  the  disease  is  con- 
tracted during  sexual  intercourse,  by  direct  contact.  Various  other  modes 
of  direct  infection  exist,  such  as  kissing,  suction  of  nipple,  biting,  digital 
examination  by  the  accoucheur,  tattooing  in  cases  where  the  operator  has 
used  his  own  saliva,  circumcision,  and  vaccination.  In  mediate  infection, 
the  contagion  is  communicated  by  means  of  instruments  contaminated 
with  the  syphilitic  virus,  such  as  drinking-vessels,  tooth-instruments,  etc. 
The  syphilitic  virus  can  apparently  retain  its  activity  in  the  dried  state 
for  many  weeks.  The  virus  is  contained  in  the  most  potent  form  in  the 
secretions  of  the  initial  lesion  and  of  the  secondary  lesions,  condylomata, 
and  mucous  patches,  as  well  as  in  the  secretions  of  similar  eruptions  in 
inherited  syphilis.  The  blood,  when  the  disease  is  active,  also  contains 
the  virus.  Many  believe  that  the  secretions  from  tertiary  lesions  are 
inert.  The  saliva,  if  the  mouth  is  healthy,  the  milk,  the  semen,  the  sweat, 
and  the  tears  are  also  believed  to  be  innocuous.  Hereditary  transmission 
may  be  from  the  father  or  the  mother.  A  woman  may  give  birth  to  a 
syphilitic  child  without  herself  showing  symptoms  of  the  disease.  In 
such  cases,  however,  the  mother  is  herself  protected,  as  is  shown  by  the 
fact  that  she  does  not  contract  syphilis  by  suckling  the  child ;  while  an 
unprotected  person,  such  as  a  wet  nurse,  would  almost  certainly  do  so. 
The  statement  of  the  immunity  of  the  mother  of  a  syphilitic  child  is 
known  as  Colles's  law,  having  first  been  enunciated  by  Abraham  Colles, 
a  Dublin  surgeon,  in  1837.  Mention  may  be  made  here  of  the  law  of 
Profeta,  to  the  effect  that  the  healthy  offspring  of  syphilitic  parents  are 
immune  to  syphilitic  infection.  This  so-called  law  rests  on  much  less 
certain  evidence  than  Colles's  law,  and  must  be  considered  as  not  proven, 
if  not  disproved. 

The  relation  of  syphilis  to  other  diseases,  such  as  tubercle  and 
cancer,  has  received  a  considerable  amount  of  study.  When  syphilis  is 
attended  with  much  debility,  probably  the  power  of  resistance  to  the 


32o  GENERAL  DISEASES. 

tubercle  bacillus  is  diminished.  Some  evidence  has  been  collected,  show- 
ing that  syphilitic  lesions,  especially  of  the  mouth  and  tongue,  may  later 
become  cancerous.  Aneurysm  is  believed  by  many  to  be  etiologically 
intimately  connected  with  syphilis. 

Syphilis  contracted  at  a  late  period  of  life  is,  as  a  rule,  more  severe 
than  when  acquired  early.  A  second  attack  may  occur,  but  it  is  certainly 
rare,  and  the  number  of  really  authentic  cases  is  few.  A  second  successful 
inoculation  generally  produces  a  milder  type  of  disease,  but  in  some  of 
the  genuine  recorded  cases  the  second  attack  has  been  very  severe. 

Morbid  anatomy.  —  Primary  sore.  —  This  consists  of  a  localised 
tumour  of  granulation  tissue,  seated  in  the  cutis  vera.  In  the  earliest 
stages  small  round  cells  are  clustered  round  the  vessels.  There  is  an 
infiltration  with  leucocytes  and  a  proliferation  of  the  connective  tissue 
cells.  In  the  later  stages  the  papillary  layer  at  the  margin  of  the  sore 
becomes  swollen,  its  interstices  being  distended  with  fluid  and  infiltrated 
with  closely-set  small  round  cells,  forming  an  indurated  edge  to  the  sore. 

The  blood  vessels  in  the  neighbourhood  of  the  lesion  early  show 
changes.  The  cells  of  the  endothelium  swell  and  proliferate ;  small  round 
cells  infiltrate  the  walls  of  the  vessels,  and  the  immediately  surrounding 
lymph  spaces  are  crowded  with  polyhedral  cells.  The  early  involvement 
of  the  vessels,  and  the  extent  to  which  they  are  affected,  are  striking 
features  of  the  primary  sore. 

Secondary  affections. — Lymphatic  glands. — The  virus  is  conveyed 
to  the  neighbouring  glands  by  means  of  the  lymphatics.  The  glands  show 
changes  similar  to  those  of  the  original  sore,  namely,  the  production  of 
granulation  tissue,  with  little  tendency  to  develop  into  ordinary  connective 
tissue,  and  no  marked  tendency  to  caseation. 

Skin  eruptions. — The  histological  changes  in  the  skin  lesions  of  the 
secondary  period  consist  of  hyperemia  and  infiltration  with  round  cells, 
the  former  being  in  excess  in  the  roseolar  eruption,  the  latter  in  the 
papular.  The  infiltrating  cells  are  similar  to  those  which  are  found  in  the 
initial  lesion  and  in  gummata,  and  the  degree  to  which  they  are  present  is 
greater  the  later  the  period  at  which  the  eruption  appears.  In  the  papules 
it  is  the  superficial  layers,  the  Malpighian  layer  of  the  epidermis,  and  the 
papilla?  which  are  affected ;  while  in  the  tubercle  the  deeper  structures  are 
involved  as  well  as  the  reticular  layer  of  the  cutis  vera  and  the  subcutaneous 
tissues.  These  simple  processes  may  be  modified  by  the  invasion  of  the 
lesions  by  pyogenic  organisms,  by  which  are  produced  the  pustular  and 
impetiginous  forms  of  eruption. 

Later  lesions. — Of  the  later  lesions,  those  which  have  a  character- 
istic anatomy  are  certain  vascular  changes  and  certain  tumour  formations 
called  gummata.  The  vascular  changes  will  be  discussed  under  a  separate 
heading. 

Gummata  are  tumours  which  at  first  are  composed  of  granulation 
tissue,  resembling  that  of  the  primary  lesion.  They  are  mainly  made  up  \ 
of  small  spheroidal  cells,  but  polyhedral  and  giant  cells  are  occasionally 
present.  Few  blood  vessels  are  contained  in  the  new  tissues.  These 
tumours  may  be  of  miliary  size,  or  as  large  as  an  egg  or  an  apple,  and 
sometimes  may  attain  even  greater  dimensions.  They  are  found  in  the 
skin,  subcutaneous  tissue,  bursas,  muscles,  bones,  periosteum,  membranes  of 
the  brain,  liver,  heart,  female  breast,  testicle,  etc.  In  an  early  stage  they 
have  a  yellowish  or  reddish  white  colour,  and  though  of  firm  consistence 
have  a  somewhat  gluey  or  gelatinous  appearance,  but  they  are  seldom  seen 


SYPHILIS.  321 

in  this  condition.  At  a  later  period  they  appear  as  greyish  white  rounded 
bodies  with  opaque  yellow  caseous  centres,  and  somewhat  translucent  firm 
fibrous  capsules.  Caseation  is  generally  widely  although  unequally  diffused, 
and  often  starts  at  a  number  of  separate  foci  in  the  interior  of  the  tumour. 
Fibrous  tissue,  infiltrated  with  small  round  cells,  forms  at  the  periphery. 
The  boundary  of  the  mature  gumma  is  not  generally  sharply  defined,  but 
the  tumour  gradually  merges  into  firm  connective  tissue,  with  processes 
ramifying  into  the  surrounding  structures.  Gummata  in  or  near  the  skin 
or  mucous  membranes  may  break  down  and  form  ulcers,  the  walls  of  which 
consist  of  tissue  similar  to  that  of  the  original  tumours.  In  the  internal 
organs  they  may  remain  unaltered  in  the  caseous  condition  for  a  long  time, 
or  they  may  undergo  gradual  absorption,  leaving  no  traces  of  their  former 
presence  except  fibrous  scars,  with  sometimes  calcareous  deposits. 

Willmot  Evans  in  a  recent  paper  discusses  the  causes  of  the  localisa- 
tion of  gummata,  which  he  regards  as  probably  the  effects  of  the  toxine 
left  behind  after  the  death  of  the  micro-organism;  the  irritant  being  a 
special  chemical  substance,  organic  though  not  organised.  He  lays  down 
two  propositions — first,  that  gummata  tend  to  appear  in  structures  poorly 
supplied  with  blood ;  and,  second,  that  impairment  of  nutrition  of  any 
tissue  is  a  great  incentive  to  the  deposition  of  gummatous  material  in  it. 
He  points  out  that  the  median  vertical  septum  of  the  tongue  is  the  least 
vascular  part,  and  here  gummata  are  the  most  frequent.  If  a  gumma 
affects  a  muscle,  it  occurs  in  the  intermuscular  septa  or  in  the  sheath.  In 
the  joints  the  capsules,  and  in  the  larynx  the  fibrous  perichondrium,  are 
most  prone  to  be  attacked.  The  vascular  tissues,  such  as  the  lung,  spleen, 
pancreas,  and  kidney,  are  rarely  attacked.  Tubercle,  on  the  other  hand, 
seeks  the  vascular  tissues.  The  effect  of  impairment  of  nutrition  is  shown 
by  the  predisposing  influence  of  injury,  or  of  interference  with  the  circula- 
tion. Injury  to  the  tibia  is  connected  with  the  frequency  of  nodes  on  its. 
crest.  The  exposed  position  of  the  knee  and  its  proneness  to  injury, 
especially  in  working  women,  explains  the  localisation  of  a  gumma  in  the 
skin  over  it.  Excessive  use  of  a  joint  may  determine  a  gumma  in  it,  as  in 
the  case  of  the  right  sterno-clavicular  joint.  The  influence  of  impairment 
of  the  circulation  is  illustrated  by  the  frequency  of  gummata  on  the  legs 
when  the  veins  are  varicose. 

Symptoms. — Acquired  syphilis. — Primary  stage. — The  duration 
between  infection  and  the  first  appearance  of  the  primary  sore  has  been 
variously  stated  as  between  ten  and  ninety  days,  but  commonly  is  between 
three  and  five  weeks.  Jonathan  Hutchinson  believes  that  the  usual  latent 
period  is  longer  than  is  generally  taught,  and,  as  a  rule,  is  five  weeks ; 
while  E.  W.  Taylor  states  that  the  average  is  between  twelve  or  fifteen  and 
twenty-one  days.  Seven  to  fourteen  days  may  elapse  after  the  first  appear- 
ance of  the  sore  before  it  acquires  diagnostic  characters.  In  eleven  patients 
inoculated  by  vaccination,  the  scar  showed  signs  of  irritability  about  five 
weeks  after  infection.  In  cases  where  the  incubation  period  is  reported  to 
have  been  unusually  short,  it  is  probable,  as  Hutchinson  suggests,  that  the 
virus  was  not  pure,  and  that  the  irritation  which  first  appeared  was  simply 
inflammatory,  and  not  specific.  In  an  outbreak  of  syphilis  following  the 
inoculation  of  the  syphilitic  virus  in  the  process  of  tattooing,  reported  by 
Surgeon  Barker,  the  incubation  period  varied  between  thirteen  and  eighty- 
seven  days.  In  three  cases,  in  which  tattooing  was  clone  on  the  same  day, 
the  periods  were  twenty-nine,  forty-seven,  and  fifty -nine  days  respectively. 

The  primary  lesion  is,  as  a  rule,  a  single  sore  (chancre)  with  indurated 
vol.  1. — 21 


122  GENERAL  DISEASES. 

base.  Induration  is  not  present  from  the  beginning,  but  requires  time  for 
its  development,  and  sometimes  it  is  absent  throughout. 

The  most  usual  site  of  the  primary  sore  is  on  the  genitals,  but  it  may 
be  found  elsewhere,  as  on  the  tongue,  lip,  tonsil,  eyelid,  nipple,  or  finger, 
and  indeed  any  part  of  the  body  may  be  successfully  inoculated.  An 
abrasion  of  the  skin  or  mucous  membrane  is  probably  necessary  for 
successful  inoculation.  Although  the  sore  is  usually  single,  the  fact  of 
there  being  several  does  not  exclude  syphilis. 

The  sore  generally  begins  as  a  minute,  round,  reddish,  excoriated  spot, 
with  smooth  polished  surface.  At  first  it  is  not  raised,  but  as  it  becomes 
older  it  becomes  more  salient,  and  forms  a  cup-shaped  ulcer  with  glossy 
indolent  surface  and  thin,  scanty  secretion,  and  a  raised,  hard,  callous  border. 
When  the  erosion  remains  superficial,  it  forms  a  thin  wafer -like  or  parch- 
ment-like mass  ;  when  it  extends  to  the  subcutaneous  tissues,  the  indura- 
tion becomes,  as  a  rule,  well  marked.  Various  forms  of  chancre  have  been 
described,  such  as  the  chancrous  erosion,  the  dry  papule,  and  the  ecthy- 
matous  chancre,  but  of  these  space  does  not  permit  a  detailed  account. 

The  lymphatic  glands  in  connection  with  the  affected  part  usually 
become  enlarged  and  indurated.  The  enlargement  is  noticeable  within  a 
few  days  of  the  appearance  of  the  sore,  and  the  induration  follows  a  little 
later.  The  glands,  which  vary  in  size  from  a  bean  to  an  almond,  are 
freely  movable  under  the  skin,  and  remain  discrete.  They  are  not  painful, 
although  they  may  be  slightly  tender  to  pressure,  and,  as  a  rule,  the 
patient  is  quite  unconscious  of  their  presence  until  his  attention  is  drawn 
to  them.  The  induration  of  the  glands  becomes  fully  developed  in  one 
or  two  weeks,  and  continues  from  a  few  weeks  to  several  months.  Suppura- 
tion is  uncommon,  and  when  it  occurs  is  due  to  the  invasion  of  the  primary 
sore  by  pyogenic  organisms.  Accompanying  the  induration  of  the  glands 
there  is  sometimes  also  induration  and  swelling  of  the  lymphatics  between 
the  sore  and  the  glands.  This  induration  runs  a  similar  course  to  that  of 
the  glands. 

Secondary  stage. — Following  the  appearance  of  the  primary  sore,  there 
is  a  second  incubation  period,  usually  lasting  about  six  weeks;  its  limits 
being  one  to  three  months.  The  secondary  stage  of  syphilis  then  sets 
in,  characterised  by  malaise  and  fever,  together  with  eruptions  on  the 
skin  and  mucous  membranes. 

The  amount  of  constitutional  disturbance  attending  the  eruptions  of  the 
secondary  period  is  subject  to  great  variations.  In  some  cases  there  may 
be  little  or  none  ;  in  others,  especially  in  women,  it  may  be  as  marked  as 
in  one  of  the  specific  fevers.  The  eruption  which  is  the  characteristic  of 
the  secondary  stage,  although  very  variable  in  form,  is  usually  coppery  or 
of  the  colour  of  raw  ham. 

The  skin. — The  secondary  syphilides  more  especially  affect  the  face, 
particularly  the  forehead  at  the  margin  of  the  hair,  forming  the  so-called 
corona  Veneris,  the  sides  of  the  nose  and  the  angles  of  the  mouth,  the  scalp, 
the  abdomen  (especially  round  the  umbilicus),  the  sides  of  the  trunk,  the 
neighbourhood  of  the  anus  and  genitals,  and  the  palms  of  the  hands  and 
the  soles  of  the  feet.  They  are  more  marked  on  the  anterior  and  inner 
aspect  of  the  limbs  than  on  the  posterior  and  outer.  They  are,  as  a  rule, 
symmetrical.  Other  characteristics  are  polymorphism,  or  the  occurrence 
of  several  varieties  of  lesion  in  the  same  patient  at  the  same  time,  the 
absence  of  itching  and  pain,  and  the  tendency  for  the  lesions  to  arrange 
themselves  in  crescents  or  rings. 


SYPHILIS.  323 

The  eruptions  are  for  the  most  part  chronic,  and  devoid  of  inflammatory 
features.  The  ordinary  secondary  eruption  takes  from  two  to  four  weeks 
for  its  full  development,  and  some  eight  weeks  for  its  decline  and  dis- 
appearance. Very  transitory  and  very  long-continued  eruptions  are  some- 
times observed.  The  most  common  as  well  as  the  earliest  rash  to  appear  is 
the  roseolar  or  macular.  This  consists  of  round  spots,  generally  pink,  but 
varying  in  shade  from  a  rosy  red  to  a  purple  colour,  and  from  a  quarter 
to  half  an  inch  in  diameter.  They  are  usually  most  marked  over  the 
abdomen.  At  first  they  fade  on  pressure,  but  later  they  cannot  be  effaced 
in  this  way.  The  eruption  sometimes  assumes  a  papular  character,  and 
quite  a  number  of  varieties  have  been  described,  such  as  the  miliary 
papular,  the  lenticular,  the  small  flat,  the  large  flat,  and  the  scaly  papular. 
It  may  also  be  of  a  pustular  type,  of  which  an  acneiform,  a  varioliform, 
an  impetiginiform,  and  an  ecthymatiform  variety  have  been  described.  A 
rare  form  of  secondary  syphilide,  described  by  French  writers  as  the 
malignant  ulcerous,  is  met  with  in  the  so-called  malignant  form  of  syphilis 
to  which  reference  will  be  made  later. 

Still  another  form  is  the  pigmentary  syphilide,  which  may  occur  alone 
or  with  other  eruptions.  This  is  most  commonly  met  with  in  females, 
especially  blondes,  up  to  the  age  of  30  or  35.  It  specially  affects 
the  lateral  surfaces  of  the  neck,  but  may  attack  the  face  and,  in 
particular,  the  forehead,  or  the  trunk,  arms,  or  legs.  It  occurs  in  several 
forms,  and  the  patches  vary  in  colour  from  a  very  light  to  a  very  dark 
brown.  After  a  time  the  colour  fades  irregularly,  and  whitish  islets  make 
their  appearance.  This  pigmentary  eruption  is  very  indolent,  and  is  but 
little  affected  by  treatment. 

In  situations  of  the  body  where  the  skin  is  usually  moist,  such  as  the 
groins,  the  vicinity  of  the  anus,  the  genitals,  the  axillse,  and  the  angles  of 
the  mouth,  the  lesions  assume  a  peculiar  character,  and  are^  termed  flat 
condylomata.  These  consist  of  flat  roundish  and  slightly  raised  discs  of  a 
greyish  red  colour.  Sometimes  the  patches  are  much  raised,  when  they 
are  called  acuminate  condylomata. 

The  affections  of  mucous  membranes. — The  eruptions  on  the  mucous 
membranes  consist  of  erythemata,  superficial  ulcers,  and  mucous  patches. 
Erythema  of  the  fauces  is  common  in  the  early  stages,  but  in  itself  cannot 
be  considered  characteristic.  The  most  typical  lesions  are  mucous  patches, 
and  their  most  characteristic  situation  is  on  the  tonsils  and  the  anterior 
pillars  of  the  fauces,  but  they  are  also  not  infrequently  present  on  the 
uvula,  the  sides  of  the  tongue,  the  mucous  surfaces  of  the  lips,  and  the 
inner  surface  of  the  cheeks  near  the  last  molar  tooth.  They  have  often 
a  greyish  white  colour,  as  if  the  mucous  membrane  had  been  pencilled 
with  nitrate  of  silver.  They  are  not,  as  a  rule,  elevated  above  the  surface. 
With  the  erythema  of  the  pharynx  there  is  usually  dryness  of  the  fauces, 
together  with  some  discomfort  or  actual  pain  on  swallowing.  When  there 
are  mucous  patches,  soreness  of  the  throat  is  often  a  marked  feature. 

A  similar  condition  to  that  in  the  pharynx  is  not  uncommon  in  the 
larynx.  Hoarseness  is  a  frequent  feature  of  the  early  secondary  stage. 
This  may  pass  into  aphonia.  Pain  on  swallowing  may  result  from  the 
affection  of  the  larynx  as  well  as  from  that  of  the  pharynx.  The  pituitary 
membrane  of  the  nose  is  also  liable  to  be  the  seat  of  erythema,  superficial 
ulceration,  and  mucous  patches.  In  women  the  vulva  is  frequently  the 
seat  of  mucous  patches.  The  lymphatic  glands  at  this  period  are  often 
slightly  swollen.     The  swelling  is  indolent  and  painless,  and  the  glands 


324  GENERAL  DISEASES. 

most  frequently  affected  are  the  anterior  and  posterior  cervical,  the  occipital, 
and  the  supraclavicular. 

Fever  is  a  common  symptom  at  the  onset  of  the  secondary  stage.  It 
seldom  makes  its  appearance  earlier  than  ten  days  before  the  rash.  It 
may  be  slight,  which  is  usual ;  or  it  may  be  intense,  which  is  rare.  A  mild 
form  of  pyrexia  is  the  usual  type,  the  highest  temperature  not  exceeding 
101°.  In  most  cases  with  papular  eruptions  the  fever  is  mild.  In  excep- 
tional cases  the  fever  may  assume  an  intermittent  or  remittent  type,  the 
higher  temperatures  reaching  104°  or  105°.  Cases  have  been  recorded 
where  febrile  temperatures  persisted  for  a  long  time,  until  treatment  with 
mercury  and  iodide  of  potassium  had  been  adopted. 

Ancemia  and  loss  of  strength  are  frequent  accompaniments  of  the 
secondary  period.  Ansemia  is  characterised  by  pallor,  with  a  slight  icteric 
tinge,  and  considerable  diminution  in  the  number  of  red  blood  corpuscles. 
Weakness  or  prostration  is  generally  much  more  marked  in  females  than  in 
males,  and  sometimes  is  extreme,  with  inability  to  stand  or  sit  up,  and 
very  feeble  cardiac  action. 

Headache  is  a  common  and  troublesome  symptom.  Following  Fournier, 
we  may  recognise  three  varieties  of  headache :  the  first  troublesome,  bub 
not  so  severe  as  to  prevent  the  patient  from  following  his  or  her  ordinary 
occupation ;  the  second  resembling  migraine ;  and  the  third  very  severe, 
accompanied  by  giddiness,  tinnitus,  and  sometimes  much  mental  depres- 
sion, and  totally  incapacitating  the  sufferer  from  work.  The  headache 
may  be  constant  or  intermittent ;  in  the  first  case  becoming  more  severe 
in  the  evening,  in  the  second  case  coming  on  only  in  the  evening.  The 
patient  may  suffer  from  headache  for  a  few  days  only,  or  for  several 
months.  Insomnia  may  be  present  with  or  without  headache,  but  it  is 
usually  in  women  that  it  is  a  marked  feature.  It  is  not  influenced  by 
ordinary  hypnotics,  but  disappears  with  antisyphilitic  treatment.  Neuralgia 
affecting  the  fifth  cranial  or  the  sciatic  nerves,  and  sometimes  the  inter- 
costal or  the  anterior  crural  nerves,  is  not  uncommon. 

The  patient  frequently,  at  this  stage,  loses  flesh,  and  suffers  from  shifting 
pains  in  the  bones  and  joints,  or  the  muscles  and  fasciae.  These  pains,  like  the 
headache,  may  be  absent  during  the  day,  but  coming  on  towards  evening  may 
be  very  distressing  during  the  night.  It  is  in  the  larger  joints,  and  in  the 
muscles  and  fasciae  of  the  extremities,  that  the  pains  most  frequently  occur. 

Synovitis  of  a  peculiar  type  occasionally  occurs.  It  is  usually  slow, 
comparatively  painless  and  intermittent.  The  amount  of  effusion  may  be 
small  or  large,  and  may  return  again,  after  disappearing  more  than  once. 
The  skin  over  the  joint  is  unaffected.  The  joint  may  be  manipulated 
without  discomfort  to  the  patient.  Under  treatment  the  effusion  slowly 
disappears.  The  joint  usually  completely  recovers,  but  may  be  left 
enlarged  and  thickened,  and  subject  to  recurrent  small  effusions.  Some- 
times one  meets  with  a  form  of  joint  affection  resembling  acute  articular 
rheumatism,  but  differing  in  its  tendency  to  remain  in  the  parts  first 
attacked.  Both  large  and  small  joints  may  be  swollen,  painful,  and 
tender.  The  condition  may  run  a  protracted  course,  and  be  accompanied 
by  pronounced  fever.  It  is  intractable  to  ordinary  anti-rheumatic 
remedies,  but  gradually  yields  to  antisyphilitic  treatment. 

The  hones  also  may  be  affected  in  the  secondary  period,  especially  the 
skull,  the  tibias,  the  ribs,  the  sternum,  and  the  clavicles.  In  the  case  of  the 
skull,  nodes  most  frequently  appear  on  the  frontal  or  parietal  bones.  The 
subcutaneous  surface  of  the  tibia,  the  upper  third  of  the  sternum,  and  the 


SYPHILIS.  325 

inner  extremities  of  the  clavicles  are  particularly  liable  to  be  attacked. 
Pain  is  sometimes  severe,  and  is  usually  worse  at  night.  On  the  whole, 
periostitis  at  this  stage  is  slight  and  transitory. 

Affections  of  the  eyes. — Iritis  may  occur  from  three  to  six  months  after 
infection,  frequently  appearing  when  the  eruption  is  at  its  height,  or  just 
beginning  to  decline.  It  is  usually  symmetrical.  Lymph  is  freely  effused, 
forming  nodules  of  a  salmon  colour  or  rusty  tint.  Ciliary  congestion  is 
generally  well  marked.  Eelapses  are  liable  to  happen,  but  in  these  much 
less  lymph  is  effused,  and  nodules  are  rarely  seen.  Along  with  iritis,  or, 
instead  of  it,  retinitis  may  come  on.  This  generally  begins  at  a  rather  later 
period  than  the  iritis.  There  are  no  subjective  symptoms,  except  dimness 
of  sight.  Ophthalmoscopic  examination  shows  haziness  of  the  retina,  which 
appears  "  as  if  stained  with  port  wine,"  and  slight  swelling  of  and  blurring 
of  the  margins  of  the  optic  disc,  together  with  small  haemorrhages. 

Affections  of  the  ears. — It  is  not  uncommon  for  the  affection,  of  the 
throat  in  the  secondary  stage  to  be  followed,  by  extension,  by  catarrh  of 
the  Eustachian  tube  and  middle  ear.  Tinnitus  and  deafness  are  the  usual 
results  of  the  chronic  aural  catarrh.  Purulent  inflammation  of  the  middle 
ear,  with  perforation  of  the  membrane,  has  not  infrequently  occurred  in  the 
secondary  stage.  Syphilitic  affections  of  the  internal  ear,  though  fortunately 
rare,  are  sometimes  observed  towards  the  end  of  the  secondary  period,  or 
about  six  months  after  primary  symptoms.  The  course  of  these  troubles 
is  sometimes  remarkably  rapid,  so  that  a  patient  may,  in  ten  days,  become 
absolutely  deaf.  It  is  the  connective  tissue  elements  which  are  probably 
affected,  damage  occurring  to  the  nerve  elements  through  their  infiltration. 
Such  affections  require  prompt  and  very  active  mercurial  treatment. 
"When  this  is  adopted  early,  they  usually  subside.  Sometimes  facial 
paralysis  accompanies  the  deafness. 

Alopecia  frequently  occurs  during  the  secondary  stage.  It  may  be 
slight  or  almost  complete.  Two  forms  of  alopecia  have  been  described.  One 
a  general  thinning,  or  more  or  less  complete  shedding,  the  other  a  falling 
out  of  the  hair  in  circumscribed  patches.  The  eyebrows,  beard,  moustaches, 
and  axillary  and  pubic  hair  may  suffer  as  well  as  the  scalp.  In  the  patchy 
form  the  scalp  often  assumes  a  moth-eaten  appearance. 

The  nails  also  are  sometimes  affected,  those  of  the  feet,  as  well  as  those 
of  the  hands.  The  changes  in  them  usually  occur  during  the  first  two 
years.  The  disorder  may  begin  in  the  nail  itself  (onychia),  or  in  its 
vicinity  (perionychia).  In  the  latter  form  the  nail  is  affected  secondarily. 
Various  forms  of  onychia  are  met  with — Onychia  sicca,  in  which  the  edge  of 
the  nail  becomes  thickened  and  brittle,  and  the  surface  rough  and  lined 
with  shallow  longitudinal  fissures  ;  hypertrophic  onychia,  when  thickening 
is  excessive ;  and  a  form  in  which  separation  of  a  portion  or  the  whole 
of  the  nail  occurs.  Similarly,  there  are  various  types  of  perionychia 
— the  ulcerative,  in  which  there  is  ulceration  with  secretion  of  pus  along 
the  attached  nail  margins ;  the  non-ulcerative,  in  which  there  is  much 
thickening  of  the  attached  margin ;  and  a  diffuse  form,  in  which  necrosis  of 
the  nail  is  apt  to  occur. 

Other  disorders  of  the  secondary  'period  which  have  been  occasionally 
observed  are  hysteria  and  analgesia.  Fournier  observed  general  analgesia 
in  one  hundred  cases  in  three  years ;  and  Taylor  has  frequently  met  with 
it  both  in  the  male  and  female.  Sometimes  it  is  accompanied  by  anaesthesia 
and  inability  to  distinguish  heat  from  cold.  Sometimes  it  is  limited  to 
certain  parts  of  the  body,  especially  the  extremities  of  the  limbs,  and  in 


326  GENERAL  DISEASES 

women  the  breasts.  Enlargement  of  the  spleen,  pleurisy,  jaundice,  and 
nephritis  are  other  occasional  complications. 

Course  and  duration. — It  must  be  borne  in  mind  that,  in  an  individual 
case,  probably  only  a  few  of  the  symptoms  mentioned  will  be  met  with. 
A  skin  eruption  and  a  sore  throat  often  comprise  the  whole  symptomatology 
of  the  secondary  period.  From  six  months  to  a  year  is  the  usual  time 
during  which  secondary  symptoms  may  appear.  The  actual  duration  of 
the  secondary  symptoms  in  a  case  adequately  treated  may  be  only  a  few 
weeks. 

The  term  malignant  syphilis  has  been  applied  to  certain  cases  in  which 
the  secondary  manifestations  of  syphilis  appear  with  unusual  rapidity,  and 
are  from  the  first  of  a  severe  type,  so  as  to  merit  the  term  malignant  syphilis. 
The  constitutional  symptoms,  such  as  general  cachexia,  fever,  anaemia, 
pains,  etc.,  are  accompanied  with  much  prostration.  The  skin  lesions  are  of 
an  ulcerative  and  pustular  type,  or  various  forms  of  rash  follow  one  another 
in  quick  succession,  so  that  the  mild  and  severe  eruptions  are  probably 
present  at  the  same  time.  The  term  malignant  syphilis  has  been  also 
applied  to  cases  of  severe  tertiary  sores,  occurring  in  debilitated  or  other- 
wise unhealthy  subjects. 

Some  think  that  malignancy  owes  its  origin  to  peculiar  virulence  of 
the  virus,  or  to  its  combination  with  pyogenic  cocci ;  others  suppose  that 
an  unusually  large  amount  of  the  virus  has  been  introduced  into  the  system ; 
while  others  hold  that  there  must  be  some  peculiar  susceptibility  in  the 
individual.  It  has  been  observed  that  cases  of  this  so-called  malignant  type 
bear  mercurial  treatment  badly,  and  better  success  is  sometimes  obtained 
by  having  recourse  to  iodides.  The  prognosis,  however,  is  on  the  whole 
good. 

Tertiary  stage. — After  the  subsidence  of  the  secondary  symptoms,  a 
period  of  more  or  less  immunity  generally  follows.  This  is  followed  in  a 
certain  number  of  cases  by  lesions  differing  widely  from  those  of  the  second- 
ary period.  They  are  slowly  evolved  and  of  chronic  duration,  insidious  in 
their  onset,  uncertain  in  their  course,  and  unattended  by  local  or  general  pre- 
monitory symptoms.  While  the  secondary  lesions  attack  the  superficial 
parts,  the  tertiary  invade  the  deeper,  the  subdermal,  and  submucous  tissues, 
the  bones,  muscles,  and  viscera.  While  the  secondary  are  symmetrical,  the 
tertiary  show  no  such  arrangement.  The  secondary  as  a  rule  undergo  spon- 
taneous retrogression,  and  seldom  if  ever  recur ;  while  the  tertiary  exhibit 
little  natural  tendency  to  resolution,  and  may  relapse  after  treatment  again 
and  again.  The  average  time  of  onset  is  about  the  third  or  fourth  year,  but 
tertiary  lesions  sometimes  develop  quite  early  or  towards  the  end  of  the  first 
year.  Haslund  gives  an  estimate,  founded  on  6364  cases  of  primary  syphilis, 
that  13  per  cent,  of  the  males  and  11 '7  per  cent,  of  the  females  have  tertiary 
symptoms.  Jonathan  Hutchinson,  from  2000  private  cases,  gives  a  much 
lower  estimate,  namely,  7"2  per  cent. ;  and  of  cases  treated  by  himself  through- 
out, the  percentage  was  much  less — little  more  than  1  per  cent.  He  believes 
that  in  cases  systematically  treated  the  occurrence  of  tertiary  symptoms  is 
quite  the  exception.  This  is  supported  by  the  evidence  collected  by 
Marschalko,  who  found,  from  the  study  of  673  cases,  that  tertiary  symptoms 
occurred  in  only  2*7  per  cent,  of  the  cases  efficiently  treated,  as  against  23-9 
per  cent,  in  the  neglected  cases. 

The  skin  eruptions  of  the  tertiary  period  are,  as  has  been  pointed  out, 
more  deeply  situated,  and  are  more  scattered,  and  more  irregularly  dis- 
tributed, than  the  secondary.     A  number  of  varieties  have  been  described, 


SYPHILIS.  327 

such  as  the  gummatous,  the  tuberculous,  the  serpiginous,  the  rupial,  and  the 
bullous.  The  gummatous  syphilide  begins  in  the  subcutaneous  tissue,  and 
the  skin  only  secondarily  becomes  affected.  The  lesions  are  commonly  few, 
but  they  may  be  very  numerous.  They  may  lead  to  extensive  ulceration  of 
the  skin.  They  affect  specially  parts  where  the  skin  is  soft  and  connective 
tissue  abundant.  Thus,  while  the  neighbourhood  of  the  joints  is  affected, 
and  the  scalp,  face,  and  neck  may  suffer,  the  palms  and  soles  escape.  Most 
of  the  tertiary  eruptions  leave  behind  them  a  coppery  stain.  The  same  is 
observed,  although  more  rarely,  after  some  of  the  secondary  eruptions. 

In  the  tuberculous  syphilide  there  are  circumscribed  infiltrations,  which 
are  deeply  seated  in  the  skin,  and  seldom  lead  to  ulceration.  Its  course  is 
very  chronic,  and  it  frequently  relapses.  The  eruption  is  attended  by  no 
subjective  symptoms,  and  unless  it  appears  early,  when  it  more  properly 
belongs  to  the  secondary  period,  is  limited  to  one  or  two  parts  of  the  body. 
Sometimes  tuberculous  rings  or  kidney-shaped  patches  are  formed,  which 
grow  at  their  periphery.  The  surface  of  such  patches  frequently  becomes 
warty  and  uneven.  The  head  and  face  are  not  infrequently  attacked,  and 
the  skin  over  the  sternum,  shoulders,  inguinal,  or  gluteal  region  may  also  be 
affected.  Over  the  buttocks  the  eruption  may  be  covered  with  scales.  This 
eruption,  although  very  persistent  if  untreated,  generally  yields  readily  to 
specific  treatment. 

The  serpiginous  syphilide,  like  the  tuberculous,  is  very  chronic,  and  may 
affect  a  large  surface  of  the  body,  creeping  along  by  ulceration  at  the  margin 
while  healing  at  the  centre.  It  may  be  deep  or  superficial.  The  margin 
is  usually  covered  with  crusts.  This  form  is  one  of  the  rarer  lesions,  and 
is  generally  late  in  making  its  appearance.  It  is  less  tractable  than  the 
tuberculous  syphilide.  Eupia  is  a  syphilide  composed  of  ulcers  covered  by 
laminated  crusts.  It  is  often  attended  by  fever,  and  points  to  a  severe 
type  of  the  disease.  It  may  occur  as  early  as  the  first  year ;  but  as  a  rule 
is  later,  appearing  towards  the  end  of  the  second  or  about  the  beginning  of 
the  third  year.  The  lesions  begin  as  red  spots,  and  develop  into  flat  pustules, 
which  dry  and  become  covered  with  greenish  brown  crusts.  The  crusts 
have  a  diameter  of  from  |  in.  to  2  in.  Underneath  the  crusts  are 
ulcers  with  greyish  red  floors  and  slightly  undermined  margins.  This 
eruption  is  always  serious  and  difficult  to  cure.  The  larger  the  lesions,  the 
graver  is  the  prognosis. 

The  bullous  syphilide  at  first  resembles  pemphigus ;  but  the  effused 
serum  soon  becomes  altered  into  pus,  which  dries  into  a  dark,  greenish, 
adherent  crust.  This  lesion  specially  affects  the  forearms  and  legs.  It  is 
always  a  late  eruption,  and,  if  untreated,  may  pass  into  a  pemphigoid 
type. 

The  internal  organs. — The  tongue,  the  pharynx,  larynx,  and  the  various 
viscera  may  be  affected  with  gummata  and  other  lesions,  which  will  be 
described  under  separate  headings.  The  blood  vessels  are  very  prone  to 
disease,  especially  the  aorta  and  the  cerebral  arteries.  The  lesions  affecting 
them  will  also  be  described  separately. 

Fever,  we  have  mentioned,  may  occur,  not  only  at  the  onset  of  the 
secondary  stage,  but  sometimes  assumes  a  chronic  form.  It  is  important 
to  bear  in  mind  that  fever  may  also  complicate  visceral  syphilis,  and  in  this 
case  the  fever  may  be  of  long  duration,  accompanied  by  malaise  and  emacia- 
tion, unless  the  nature  of  the  disease  is  recognised  and  appropriate  treatment 
adopted. 

To  complete  our  account  of  acquired  syphilis,  brief  mention  must  here 


328  GENERAL  DISEASES 

be  made  of  certain  affections  of  the  eyes,  subcutaneous  tissues,  muscles, 
joints,  and  bones. 

The  eyes. — We  have  seen  that  retinitis  may  occur  about  the  same 
time  as  iritis.  Choroiditis  frequently  is  associated  with  retinitis,  and  may 
occur  from  six  months  to  two  years  after  infection.  It  usually  affects 
both  eyes,  and  often  gives  rise  to  opacities  in  the  vitreous.  The  lesions 
may  be  limited  to  the  peripheral  portions,  and  cause  little  damage  to  sight, 
or  may  involve  the  retina  and  disc,  and  progress  to  almost  total  blindness. 
Optic  neuritis,  when  it  occurs,  is  usually  secondary  to  cerebral  gummata. 
The  oculomotor  nerves  are  apt  to  suffer.  The  third  is  more  commonly 
affected  than  the  sixth,  and  the  sixth  than  the  fourth.  Symmetrical  en- 
largement of  the  lachrymal  glands  is  one  of  the  rarer  affections.  The 
tumours  first  produce  ptosis,  and  sometimes  puffiness  and  slight  redness  of 
the  eyelids,  and  later  are  apt  to  involve  the  nerves  and  muscles  of  the  eye- 
balls, thus  limiting  movement  and  producing  anaesthesia  of  forehead  and 
scalp.     Perfect  recovery  follows  efficient  treatment. 

The  subcutaneous  tissues. — These  are  frequently  the  seat  of  gummata. 
Where  adipose  or  cellular  tissue  is  abundant,  such  tumours  may  long  exist 
without  the  skin  becoming  involved.  Gummata  of  the  scalp  seldom  form 
isolated  tumours.  The  integument  as  a  whole  becomes  thickened  and 
adherent  to  the  bone,  which  is  usually  also  involved.  On  the  face,  how- 
ever, there  may  be  movable  subcutaneous  tumours  as  well  as  diffuse 
infiltrations.  The  latter  may  lead  to  serious  distortion.  Gummata  are 
not  infrequent  in  the  female  breasts.  They  form  painless  tumours  of  slow 
growth,  and  of  moderate  hardness.  The  axillary  glands  remain  unaffected. 
Gummata  of  the  gluteal  regions  and  of  the  thighs  sometimes  attain  a 
remarkable  size.  Subcutaneous  gummata  may  be  seated  over  nerves,  and 
give  rise  to  severe  pain.  In  the  lower  extremities,  what  have  been  called 
cellular  nodes  are  not  uncommon,  usually  occurring  near  the  knee,  and 
more  often  in  women  than  in  men.  The  node  ultimately  ulcerates,  and 
shows  a  core  which  has  been  likened  in  appearance  to  soaked  wash- 
leather.  The  subcutaneous  bursas  are  not  infrequently  attacked,  especially 
the  bursas  patellae.  Gummata  form  in  them  insidiously  without  pain,  and 
ulceration  occurs  in  the  same  way  as  in  the  case  of  the  cellular  node.  In 
these  cases  there  is  sometimes  a  history  of  traumatism. 

The  muscles. — Two  forms  of  affection  of  muscles  have  been  described. 
They  are  among  the  more  remote  sequelae  of  syphilis,  and  are  decidedly 
rare.  A  form  of  myositis  has  been  observed,  tending  to  more  or  less 
permanent  contraction  of  the  muscle.  Between  the  interstices  of  the 
muscular  tissue  there  is  a  development  of  connective  tissue,  which  con- 
tracts and  ultimately  destroys  the  muscle  fibres.  Such  an  affection  has 
been  most  frequently  observed  in  the  case  of  the  biceps.  Contraction 
gradually  takes  place,  and  the  only  change  observed  is  an  apparent  diminu- 
tion in  the  length  of  the  muscle.  The  limb  becomes  flexed,  and  cannot 
be  completely  extended.  In  some  cases  there  is  no  pain,  in  others  there 
is  a  dull  achrng.  The  affection  tends  to  be  progressive,  unless  suitably 
treated,  but  it  may  be  recovered  from  spontaneously. 

Gummata  develop  slowly  in  muscles,  without  pain.  There  is  usually 
very  considerable  and  well-defined  induration.  Sometimes  a  large  mass  of 
muscle  becomes  involved.  The  substance  of  the  tongue  is  more  frequently 
affected  than  other  muscles.  The  sterno-mastoid,  the  masseter,  the  supra- 
and  infra-spinatus,  the  gastrocnemius,  and  the  rectus  femoris,  are  specially 
mentioned  by  Jonathan  Hutchinson  as  liable  to  be  affected.     Muscular 


SYPHILIS.  329 

gummata  are  of  various  shapes  and  sizes,  and  may  be  flat,  fusiform, 
globular,  or  irregular.  They  are  frequently  situated  near  the  ends  of 
muscles.  Exceptionally  they  break  down  and  form  deep  ulcers.  The 
tendons,  especially  near  their  insertions  and  in  the  thicker  portions,  and 
the  tendinous  sheaths  may  also  be  affected. 

The  joints. — The  joints,  which  as  we  have  seen,  may  be  affected  in 
the  secondary  stage,  are  very  rarely  involved  in  the  later  stages.  It  is 
usually  the  larger  joints,  especially  the  knees,  which  suffer.  The  type  of 
affection  is  subacute.  The  joints  become  swollen,  from  thickening  of  the 
ligaments  and  the  fibrous  and  loose  connective  tissue  surrounding  the  cap- 
sule, and  from  gummatous  infiltration  of  these  tissues  or  of  the  cartilages 
or  epiphyses.  Effusion  usually  comes  on  slowly,  and  pain  may  or  may  not 
be  a  marked  symptom.  These  joint  affections  yield  less  readily  to  treat- 
ment than  those  of  the  earlier  period,  and  it  is  very  important  that  vigorous 
antisyphilitic  measures  should  be  employed  before  there  is  much  thickening 
and  consequent  impairment  of  movement.  In  several  instances  collected 
by  Jonathan  Hutchinson,  jun.,  the  joint  lesion  was  the  only  existing 
symptom  of  late  syphilis. 

The  bones. — Affections  of  the  periosteum  and  bone  are  among  the 
most  frequent  of  the  tertiary  lesions  of  syphilis.  Periosteal  nodes  seldom 
occur  earlier  than  two  years  from  infection,  and  often  are  much  later. 
The  superficial  bones,  such  as  the  tibiae,  the  ulnae,  the  clavicles,  the  sternum, 
and  the  calvaria,  are  most  liable,  probably  on  account  of  their  exposed 
situation.  The  palate  bones,  the  bones  of  the  nose,  and  the  alveolar  pro- 
cesses of  the  maxillae,  are  also  frequently  affected. 

Nodes  are  ill-defined  doughy  tumours,  adherent  to  the  bone  but  not 
to  the  skin.  They  consist  of  inflammatory  tissue  in  the  substance  of  the 
periosteum  or  between  it  and  the  surface  of  the  bone.  They  are  usually 
the  seat  of  severe  nocturnal  pains.  Sometimes  the  affected  bone  becomes 
greatly  thickened  and  more  dense,  as,  for  instance,  in  the  case  of  the 
calvaria.  Nodes  may  develop  on  the  internal  aspect  of  the  skull  as  well 
as  on  the  external,  and  various  cerebral  symptoms  may  ensue.  Some- 
times the  node  becomes  indurated,  and  eburnated  bony  tissue  develops, 
forming  an  exostosis.  On  the  other  hand,  suppuration  may  take  place, 
with  the  formation  of  a  periosteal  abscess,  or  an  ulcer  exposing  the  bone, 
portions  of  which  may  separate  by  exfoliation. 

Hereditary  syphilis. — The  symptoms  of  hereditary  syphilis  consist  in 
the  presence  of  certain  eruptions  on  the  skin,  together  with  a  form  of  nasal 
catarrh,  commonly  first  known  as  snuffles.  These  symptoms  usually  appear 
about  the  third  week.  Exceptionally  they  are  present  when  the  child  is 
born.     In  other  cases  they  may  not  appear  till  about  the  twelfth  week. 

The  rashes,  usually  copious  and  symmetrical,  are  as  variable  as  in  acquired 
syphilis,  but  the  commoner  are  erythematous,  eczematous,  or  papular. 
The  erythema  is  characterised  by  its  abrupt  margin  and  its  red  or  coppery 
tint.  Dry,  scaly,  vesicular,  pustular,  or  bullous  eruptions  may  also  be  met 
with.  The  rash  is  generally  well  marked  on  the  nates,  the  thighs,  and 
the  genitals,  and  condylomata  may  also  be  observed  about  these  parts. 
Mucous  patches  are  frequently  present  on  the  mucous  membrane  of  the 
mouth,  especially  about  the  angles  of  the  lips  and  the  mucous  surface  of  the 
cheeks,  the  fauces,  tonsils,  and  the  sides  and  dorsum  of  the  tongue.  The 
secretion  from  these  patches  is  abundant,  and  is  highly  infective. 

Snuffles  results  from  an  inflammatory  condition  of  the  nasal  mucous 
membrane.     It  is  not  only  one  of  the  earliest  symptoms,  but  also  one  of  the 


330  GENERAL  DISEASES. 

most  constant.  There  is  swelling  of  the  mucous  membrane,  together 
with  a  serous  discharge,  which  may  interfere  with  respiration,  especially 
during  sleep  and  suckling.  The  obstacle  to  the  breathing  gives  rise  to 
the  characteristic  snuffling  sound.  The  discharge,  at  first  thin,  presently 
becomes  thick,  and  dries  into  crusts.  Sometimes  it  is  blood-stained,  and 
it  may  be  offensive.  In  mild  cases,  the  affection  is  nothing  more  than  an 
erythema ;  but  in  the  severer  cases  there  is  ulceration  of  the  mucous 
membrane,  the  bones  become  affected,  and  the  destruction  of  bone  may 
be  followed  by  serious  deformity. 

Although  the  victims  of  hereditary  syphilis  may  be  born  healthy- 
looking,  it  is  soon  apparent  that  they  do  not  thrive.  They  waste,  lose 
colour,  and  acquire  a  wizened  appearance.  The  skin  of  the  face  is  sallow, 
and  tightly  stretched  over  the  bones,  while  that  of  the  body  is  loose  and 
wrinkled.  The  little  patients  look  like  little  old  men  or  women.  The 
bones  are  often  affected  early.  The  most  characteristic  lesions  are 
swellings  at  the  junction  of  epiphyses  and  shafts,  forming  collars  or 
rings.  The  bones  most  usually  affected  are  those  of  the  forearms,  arms, 
legs,  and  thighs,  together  with  the  clavicles,  sternum,  and  ribs.  The  distal 
extremity  is  more  likely  to  be  the  seat  of  disease  than  the  proximal,  but 
the  sternal  end  of  the  clavicle  is  a  common  situation.  The  joints  may  be 
secondarily  affected,  and  suppuration  may  occur  from  this  cause  as  well  as 
independently.  Mention  must  also  be  made  of  a  very  characteristic  joint 
affection  which  occurs  fairly  frequently  during  childhood  or  at  puberty,  and 
takes  the  form  of  a  chronic  effusion  into  one  or  more  joints,  especially  the 
knees.  It  is  symmetrical,  and  as  a  rule  almost  painless.  It  may  subside 
spontaneously  after  a  month  or  two,  or  may  persist  for  a  year  or  more.  It 
is  usually  observed  in  association  with  interstitial  keratitis,  which  it  more 
frequently  follows  than  precedes.  Antisyphilitic  treatment  is  usually 
quite  successful  in  removing  all  traces  of  the  malady.  Periostitis  is  usually 
a  late  disorder.  Dactylitis,  especially  of  the  proximal  phalanges,  is  a  very 
characteristic  lesion.  In  this  affection  the  bones  may  be  very  greatly 
enlarged,  and  the  overlying  tissues  may  swell  and  suppurate.  Onychia  is 
less  common  than  in  acquired  syphilis,  but  is  met  with  in  two  forms — 
ulcerative  and  non-ulcerative. 

Gastric  and  intestinal  disorders  are  not  infrequent,  but  are  probably 
not  of  specific  origin.  The  spleen  is  frequently  enlarged — in  half  of  the 
cases,  according  to  Gee,  while  in  one-fourth  the  hypertrophy  is  excessive. 
Pericellular  cirrhosis,  with  or  without  gummata,  also  occurs.  Affections  of 
the  liver  are  further  discussed  under  a  separate  heading.  The  pancreas 
sometimes  undergoes  degeneration.  It  becomes  abnormally  firm  and  of 
a  glistening  white  colour,  due  to  great  increase  of  the  interstitial  connective 
tissue. 

General  adenitis  does  not  occur  in  the  inherited  form.  When  the 
cervical  glands  are  affected,  this  is  secondary  to  lesions  of  the  mouth  and 
throat.  Occasionally  abscesses  or  a  diffuse  suppurative  inflammation  in 
the  substance  of  the  thymus  have  been  observed. 

The  larynx  is  occasionally  affected,  but  seldom  in  children  younger  than 
seven  years.  Ulceration  of  the  epiglottis,  with  exposure  of  the  cartilage,  is 
the  usual  form ;  but  there  may  be  general  ulceration  of  the  upper  part  of 
the  larynx,  with  resulting  stenosis.  The  lungs  may  be  attacked  with  a 
form  of  broncho-pneumonia  and  with  gummata,  but  specific  lesions  are 
decidedly  uncommon,  as  they  are  in  the  acquired  form. 

Lesions  of  the  kidneys  are  sometimes  observed,  due  to  proliferation  of 


SYPHILIS.  331 

the  connective  tissue  and  fatty  degeneration  of  the  epithelium.  The 
suprarenals  may  be  enlarged.  Affections  of  the  testicles  are  rarer  than  in 
acquired  syphilis.  Orchitis  may  occur  between  the  ages  of  3  and  12, 
but  may  be  met  with  later. 

Iritis  is  one  of  the  rarer  early  manifestations  of  hereditary  syphilis. 
It  usually  occurs  about  the  age  of  5  months.  It  may  or  may  not  be 
symmetrical.  Subjective  symptoms  are  slight.  The  effusion  of  lymph  is 
great,  and  there  is  danger  of  occlusion  of  the  pupil.  It  responds  well  to 
mercurial  treatment,  which  may  procure  the  complete  absorption  of  the 
effused  lymph. 

Although,  as  a  rule,  the  earlier  manifestations  of  hereditary  syphilis 
tend  to  spontaneous  cure,  death  is  not  an  uncommon  result. 

During  the  later  period  the  patient  may  be  free  from  symptoms. 
Growth  and  general  development  may  advance  very  slowly.  While  the 
infant  looks  old,  the  adolescent  appears  infantile.  The  youth  of  18  or  20 
may  well  pass  for  12.  According  to  Jonathan  Hutchinson,  however,  this 
is  a  very  untrustworthy  indication,  and  he  thinks  that  in  most  cases  no  retar- 
dation of  general  growth  is  observable.  He  considers  a  pale  complexion 
as  the  rule.  The  physiognomy  is  peculiar :  the  forehead  may  be  prominent, 
with  protuberant  frontal  eminences,  the  bridge  of  the  nose  sunken,  and 
the  upper  incisor  teeth  prematurely  lost.  The  rash  of  infantile  syphilis, 
once  it  has  disappeared,  seldom  returns,  but  it  leaves  its  traces.  There 
are  often  pit  marks  and  linear  scars  near  the  angles  of  the  mouth. 

The  permanent  teeth. — All  the  incisor  teeth  may  be  dwarfed  and  de- 
formed, but  it  is  the  upper  central  incisors  in  which  the  changes  are  most 
marked.  The  typical  tooth  is  short  and  narrow,  and  there  is  atrophy  of 
its  middle  part,  causing  a  single  broad  vertical  notch  in  the  edge,  from 
which  sometimes  a  shallow  furrow  passes  upwards  on  both  anterior  and 
posterior  surfaces.  The  tooth  is  narrower  at  the  cutting  edge  than  at  the 
root,  and  from  this  circumstance  is  often  described  as  peg-like.  The 
affected  teeth  sometimes  converge  and  sometimes  diverge,  or  they  may 
stand  widely  apart.  The  malformation  is  not  shown  in  the  milk  teeth. 
Only  the  permanent  teeth  are  affected.  Jonathan  Hutchinson  first 
described  these  changes.  He  says  that  he  has  never  yet  seen  such  teeth 
excepting  in  patients  who  are  the  subjects  of  inherited  syphilis ;  but  that 
in  the  majority  of  cases,  however,  the  condition  of  the  teeth  is  sufficient 
only  to  excite  suspicion  and  not  to  decide  the  question  of  this  disease.  In 
a  few  rare  cases,  only  one  of  the  central  incisors  may  be  deformed. 

Syphilitic  keratitis. — Both  eyes  are,  as  a  rule,  simultaneously  affected. 
The  cornea  becomes  generally  opaque  from  the  effusion  of  lymph  into  its 
substance.  Ciliary  congestion  is  an  early  symptom.  At  first  cloudiness 
appears  in  patches,  the  surface  looks  steamy,  and  later  the  whole  cornea 
becomes  hazy,  presenting  a  ground-glass  appearance.  The  tint  may  vary 
from  a  dull  grey  to  a  red  salmon  colour.  There  is  usually  considerable 
photophobia.  In  many  cases  iritis  occurs,  with  the  formation  of  posterior 
synechias.  While  the  condition  persists,  the  patient  is  almost  completely 
blind.  After  lasting  several  months,  the  opacity  clears  away,  but  generally 
leaves  traces,  slight  clouds  remaining  here  and  there  in  the  cornea,  together 
with  some  duskiness  of  the  sclerotic  in  the  ciliary  region.  Keratitis  usually 
occurs  between  6  and  the  age  of  puberty,  but  it  may  occur  as  early  as 
2  or  3  years,  and  it  has  been  observed  as  late  as  35. 

In  forming  an  opinion  as  to  whether  a  patient  has  been  affected  by 
inherited  syphilis,  examination  of  the  eyes  is  often  most  helpful.     They 


332  GENERAL  DISEASES 

should  be  examined  both  by  direct  illumination  with  the  help  of  a  lens, 
and  by  the  ophthalmoscope.  Tags  resulting  from  past  iritis,  and  nebulae 
on  the  corneae,  may  be  of  great  assistance  in  completing  the  evidence  in  a 
doubtful  case. 

Deafness. — It  has  been  estimated  that  the  ears  are  affected  in  10  per 
cent,  of  all  children  with  inherited  syphilis.  The  middle  or  internal  ear 
may  be  disordered,  and  total  deafness  may  be  produced.  The  disturbance 
of  hearing  may  first  occur  at  puberty. 

Gkimmata  may  occur  in  various  organs  at  a  late  period  in  hereditary 
syphilis.  In  the  account  of  visceral  syphilis,  further  mention  will  be  made 
of  these  lesions. 

Visceral  syphilis. — Digestive  system. — The  tongue. — Superficial  affec- 
tions are  common  in  the  secondary  stage.  There  may  be  hyperemia, 
accompanied  by  excoriated  or  smooth,  round,  or  oval  patches.  Mucous 
patches  are  frequent  along  the  sides  and  tip.  Fissures  may  appear  over 
the  dorsum  or  sides.  In  later  syphilis  we  meet  with  two  main  forms — 
sclerosis  and  gummata.  Sclerosis  may  be  superficial  or  deep,  but  in  either 
case  it  affects  the  upper  surface,  especially  the  vicinity  of  the  middle  line. 
In  superficial  sclerosis,  the  lesion  is  limited  to  the  mucous  membrane,  and 
there  is  a  lamellated  induration,  which  may  be  circumscribed  or  diffuse. 
In  deep  sclerosis,  the  muscular  tissue  as  well  as  the  mucous  membrane  is 
involved.  The  tongue  is  increased  in  size.  Its  surface  is  lobulated  and 
furrowed,  in  consequence  of  the  contraction  of  the  newly-formed  con- 
nective tissue.  The  mucous  membrane  itself  may  be  pale  and  smooth. 
Gummata  may  form  either  superficially,  or  in  the  substance  of  the  muscle. 
Ulcers  are  usually  multiple,  are  always  on  the  upper  surface,  and  are 
frequently  central,  or  situated  at  the  sides  or  tip.  They  are  not  usually 
painful,  and  the  glands,  as  a  rule,  are  not  involved. 

The  pharynx.  —  The  affections  of  the  secondary  stage  have  been 
previously  alluded  to.  Tertiary  lesions  of  the  soft  palate  are  not  un- 
common. Gummata  may  form  within  its  substance,  and  before  the  patient 
makes  any  complaint  perforation  may  have  occurred.  Sometimes  the 
soft  palate  and  uvula  have  been  already  destroyed  by  ulceration  when  the 
patient  first  seeks  advice.  Absence  of  pain  is  a  characteristic  of  these 
lesions,  and  accounts  for  the  fact  that  they  are  allowed  to  make  such 
ravages.  Gummata  may  also  form  in  the  pharyngeal  wall,  giving  rise 
first  to  prominent  roundish  swellings  covered  by  congested  mucous 
membrane,  and  later  to  deep  crater-like  ulcers  with  raised  margins  and 
floors  covered  with  yellow  pus.  Considerable  deformity  may  result  from 
such  lesions.  Ulceration  is  followed  by  cicatricial  contraction.  The 
remains  of  the  soft  palate  may  become  adherent  to  the  pharyngeal  wall, 
and  only  a  very  narrow  opening  may  be  left  leading  to  the  naso-pharynx. 

The  salivary  glands  are  rarely  affected.  The  parotid  occasionally 
becomes  swollen  during  the  period  of  active  symptoms.  Small  tumours, 
probably  gummata,  occasionally  appear  in  the  sublingual  gland. 

The  cesophagus. — Syphilis  of  the  oesophagus  is  extremely  rare,  and,  as 
far  as  is  known,  only  occurs  in  the  tertiary  period.  Only  twelve  undoubted 
cases  had  been  recorded  up  to  1890.  These  have  been  of  the  nature  of 
gummatous  ulceration,  leading  to  stricture. 

The  stomach  and  intestines.  —  Syphilis  of  the  stomach  is  likewise 
extremely  rare,  and  only  fourteen  of  the  cases  recorded  up  to  1898  have 
been  properly  verified ;  of  these  cases  five  were  of  the  inherited  and  nine 
of  the  acquired  form.     The  lesions  met  with  have  been  gummata,  origin- 


SYPHILIS. 


333 


ating  in  the  submucous  tissue,  and  chronic  ulcers.  The  gummata  form 
flat  plaque-like  tumours,  and  are  more  commonly  multiple  "than  single. 
The  ulcers  are  more  often  single  than  multiple.  Syphilitic  ulcers  in  parts 
of  the  intestinal  tract,  other  than  the  rectum,  have  been  recorded,  but  are 
very  rare. 

The  rectum. — The  rectum  is  not  very  infrequently  the  seat  of  syphilis  in 
women,  but  hardly  ever  in  men.  Taylor  describes  three  forms  of  rectal 
syphilis — (a)  The  extension  of  indurating  oedema  from  the  vulva  or  vagina 
to  the  rectum,  leading  to  the  production  of  more  or  less  complete  rings  of 
connective  tissue,  situated  either  between  the  two  sphincters,  or  about  1,2, 
or  3  in.  above  the  internal  one.  This  occurs  either  early  or  late  in  the  disease, 
but  usually  in  the  secondary  or  early  tertiary  stage,  (b)  Gummatous  infiltra- 
tion producing  patches  of  thickened  mucous  membrane,  some  little  distance 
from  the  anus,  (c)  The  development  of  a  form  of  infiltration  with  the  pro- 
duction of  new  connective  tissue,  without  congestion  or  exudative  products. 
An  annular  stricture  may  in  this  way  be  produced  long  after  the  activity  of 
the  disease  has  ceased.     The  process  is  one  of  very  slow  progress. 

Liver. — The  liver  is  probably  more  frequently  attacked  by  syphilis 
than  any  other  internal  organ.  Three  forms  have  been  described — 
perihepatitis,  gummatous  hepatitis,  and  diffuse  hepatitis.  It  would  be 
impossible  to  conclude  that  perihepatitis  was  syphilitic,  unless  it  were 
associated  with  other  lesions,  such  as  the  fibrous  scars  left  by  gummata 
or  gummata  themselves.  At  the  same  time  its  association  with  other 
lesions  does  not  prove  it  to  be  itself  syphilitic. 

Gummatous  hepatitis  is  the  most  characteristic  form.  Gummata  are 
found  in  the  liver  in  both  congenital  and  acquired  syphilis.  They  are  more 
common  in  cases  of  delayed  congenital  syphilis  than  in  young  children,  and 
in  the  acquired  form  they  rarely  occur  during  the  first  two  years  of  the 
disease.  As  observed  at  post-mortem  examination,  the  gummata  are  found 
surrounded  by  cicatricial  fibrous  tissue,  producing  scarring  of  the  surface. 
The  gumma  is  caseous  at  its  centre,  while  sometimes  the  vessels  at  its 
periphery  are  dilated.  The  centre  varies  in  consistence  from  that  of 
cream  cheese  to  a  gristle-like  toughness,  or  it  may  be  of  almost  bony 
hardness  from  calcareous  deposit.  Fibrous  bands  may  extend  in  various 
directions  from  the  fibrous  periphery  of  the  gumma.  The  gummata  vary 
in  size  and  number  in  different  cases.  Sometimes  they  may  produce  great 
puckering  and  deformity  of  the  or^an. 

The  diffuse  form  of  syphilitic  hepatitis  is  most  commonly  met  with  in 
congenital  syphilis,  and  generally  in  quite  young  children,  although  I  have 
recorded  a  case  occurring  at  as  late  an  age  as  15.  The  organ  is  large, 
heavy,  tough,  and  of  normal  shape,  and  great  increase  in  comiective  tissue 
is  to  be  made  out.  This  not  only  surrounds  groups  of  lobules,  but  is 
abundantly  present  in  the  lobules  themselves,  passing  between  individual 
cells,  or  encircling  groups  of  small  cells.  Miliary  gummata,  consisting  of 
small-celled  infiltrations,  are  frequently  to  be  met  with.  The  liver  cells, 
from  the  compression  to  which  they  are  exposed,  here  and  there  are 
atrophied  or  fatty.  Larger  gummata  are  not  frequent  in  this  form  of 
hepatitis,  although  they  do  occur. 

Acquired  syphilis  of  the  liver  is  more  frequently  observed  in  men  than 
in  women.  It  is  most  common  from  three  to  seven  years  after  infection. 
Earely  it  occurs  during  the  first  year.  It  may  occur  as  late  as  twenty-five 
years  after  infection.  In  some  o£  the  cases  there  is  a  distinct  history  of 
trauma. 


334  GENERAL  DISEASES. 

In  the  gummatous  form  the  liver  will  probably  be  palpably  enlarged, 
and  a  hard:  nodular  mass  may  be  felt  in  the  epigastric  region  or  right 
hypochondrium.  Apart  from  the  presence  of  the  tumour,  the  patient  may 
have  no  symptoms,  but  jaundice  and  fever  may  be  present.  In  such  cases 
a  history  of  syphilis  is  a  most  important  aid  to  diagnosis.  Confirmatory 
evidence  may  be  obtained  by  examination  of  the  eyes,  and  the  finding  of 
opacities  of  the  cornese,  signs  of  old  iritis  or  choroidal  changes,  or  by  the 
presence  of  scars  on  the  shins,  fauces,  or  elsewhere.  Fever  is  by  no  means 
a  constant  symptom.  It  was  present  in  a  well-marked  case  of  syphilitic 
tumour  of  the  liver,  in  a  boy  under  my  observation,  and  disappeared  as 
soon  as  treatment  with  iodide  of  potassium  was  started.  Pain  is  not  an 
infrequent  symptom,  but  it  is  seldom  severe  except  where  there  is 
perihepatitis.  In  diffuse  syphilitic  hepatitis,  jaundice  is  a  common 
symptom.  Ascites  may  or  may  not  be  present.  The  spleen  is  not 
uncommonly  enlarged  as  well  as  the  liver.  When  amyloid  disease  coexists, 
there  may  be  albuminuria.  A  mild  transitory  form  of  jaundice,  coming 
on  suddenly  and  lasting  a  few  weeks,  is  sometimes  observed  during  the 
secondary  period  of  syphilis,  or  in  the  course  of  the  first  year.  It  is  not 
usually  accompanied  by  loss  of  appetite  and  disordered  digestion,  as  in 
ordinary  catarrhal  jaundice.  It  is  readily  influenced  by  antisyphilitic 
treatment.  A  severe  form  of  jaundice,  the  pathology  of  which  is  obscure, 
has  been  described  as  a  late  symptom  in  the  course  of  syphilis.  The 
jaundice  is  intense  and  persistent,  and  is  accompanied  by  cachexia, 
headache,  and  neuralgia. 

The  pancreas. — Syphilitic  disease  of  the  pancreas  is  very  rare  in 
acquired  syphilis,  and  then  generally  takes  the  form  of  gummatous 
infiltration.  It  is  more  common  in  hereditary  syphilis,  and  not  a  few 
cases  have  been  observed  in  infants  and  new-born  children.  The  pancreas 
may  be  attacked  as  early  as  the  fifth  month  of  gestation.  Gummata  are 
rare,  the  disease  usually  taking  the  form  of  a  diffuse  interstitial  pancreatitis. 
The  organ  is  not  much  enlarged,  but  is  increased  in  weight  and  is  always 
abnormally  firm  in  consistence.  In  typical  cases  it  may  be  as  tough  as 
cartilage.     The  disease  as  a  rule  is  more  advanced  towards  the  head. 

Lymphatic  system. — The  lymphatic  glands. — It  has  been  mentioned 
that  there  is  a  general  enlargement  of  the  subcutaneous  lymphatic  glands  in 
the  secondary  stage  of  syphilis,  in  addition  to  the  early  enlargement  of  the 
glands  which  are  in  immediate  anatomical  relation  to  the  primary  lesion. 
The  enlargement  is  most  obvious  in  the  glands  which  are  most  easily 
accessible,  such  as  the  anterior  and  posterior  cervical,  the  supraclavicular, 
the  posterior  auricular,  the  occipital,  the  epitrochlear,  and  the  axillary. 
The  superficial  lymphatic  glands  may  again  be  affected  in  late  syphilis, 
but  are  not  enlarged  secondarily  to  lesions  of  skin,  mucous  membranes,  or 
muscles,  an  important  point  in  establishing  a  diagnosis  between  syphilis 
and  cancer.  The  deep  lymphatic  glands  may  be  affected  in  tertiary 
syphilis.  Thus  the  glands  in  anatomical  relation,  with  a  tertiary  lesion 
of  one  of  the  internal  organs,  may  become  indolently  enlarged.  Inde- 
pendently of  any  local  lesion,  the  prevertebral,  the  lumbar,  the  iliac, 
and  the  deep  inguinal  glands  may  be  enlarged,  and  be  either  soft  or 
indurated. 

The  spleen. — Swelling  of  the  spleen  is  not  uncommon  during  the 
secondary  period.  According  to  Quinquand  and  Kicolle,  enlargement  of 
this  organ  is  one  of  the  early  symptoms  of  general  infection,  and  may  be 
noticed  soon  after  the  appearance  of  the  chancre  before  either  skin  or  throat 


SYPHILIS.  335 

troubles  have  occurred.  At  later  stages  the  spleen  may  be  affected,  either 
with  an  interstitial  infiltration  or  with  gummata.  Both  of  these  are 
decidedly  rare,  and  are  chiefly  met  with  in  congenital  cases.  In  the 
interstitial  form,  the  organ  is  permeated  by  bands  of  connective  tissue, 
usually  following  the  course  of  the  blood  vessels.  Gummata  may  be 
solitary  or  multiple,  deeply  seated  or  at  the  surface,  and,  while  ordinarily 
small,  varying  in  size  from  a  hempseed  to  a  walnut,  are  sometimes  very 
large,  forming  a  considerable  portion  of  a  much  enlarged  spleen.  When 
recent  they  are  of  a  reddish  grey  colour,  somewhat  denser  and  tougher 
than  the  normal  spleen  substance.  The  older  lesions,  like  those  in  the 
liver,  are  embedded  in  scar-like  cicatricial  tissue.  With  either  form  the 
capsule  is  usually  thickened,  and  this  may  also  occur  independently. 
Lardaceous  degeneration  may  be  met  with  both  in  acquired  and  congenital 
syphilis. 

The  vascular  system. — Tlie  heart. — Syphilitic  affections  of  the  heart 
may  be  classified  as  follows — Gummata ;  fibroid  induration ;  amyloid 
degeneration ;  infarctions  caused  by  endarteritis  obliterans. 

Gummata  are  usually  met  with  in  the  wall  of  the  left  ventricle,  or 
more  rarely  in  that  of  the  right.  They  are  commonly  single,  although 
occasionally  multiple.  Their  size  ordinarily  varies  between  a  bean  and  a 
hazel-nut,  but  they  have  been  met  with  as  large  as  a  hen's  egg.  It  is 
seldom  that  an  opportunity  occurs  for  seeing  them  in  the  recent  stage. 
Loomis  observed  one  of  a  reddish  or  reddish  grey  colour  and  homo- 
geneous structure,  which  was  co-existent  with  a  well-marked  gumma  of 
the  liver.  The  old  gummata  are  of  a  grey  or  greyish  yellowish  colour,  of 
firm  consistency  and  of  homogeneous  structure.  The  centre  is  lighter  in 
colour,  of  cheesy  appearance,  but  firm.  The  tumours  are  not  circumscribed, 
but  blend  insensibly  with  the  surrounding  muscle,  the  gummatous  tissue 
being  continued  between  the  fibres.  The  peripheral  part  is  composed  of 
small  cells,  but  the  caseous  centre  distinguishes  the  tumour  from  sarcoma. 
It  is  not  always  easy  to  differentiate  gummata  of  the  heart  from  tuberculous 
lesions.  The  absence  of  bacilli  and  the  presence  of  syphilitic  lesions  else- 
where are  the  chief  points  in  favour  of  syphilis. 

The  fibroid  induration  produced  by  syphilis  closely  resembles 
ordinary  fibroid  disease  of  the  heart ;  in  fact,  it  is  only  its  association 
with  other  evidences  of  syphilis,  such  as  gummata  of  other  organs,  which 
points  to  its  syphilitic  character.  The  fibroid  patches  are  found  most 
commonly  in  the  wall  of  the  left  ventricle,  near  the  apex  or  at  the  base 
near  the  aorta.  The  heart,  as  a  rule,  is  hypertrophied,  and  the  cavities  are 
dilated.  The  fibrosis  may  be  limited  to  a  well-defined  area  in  the 
substance  of  the  muscle,  from  which  the  muscle  fibres  have  quite 
disappeared.  There  may  be  diffuse  irregular  patches  of  new  fibrous  tissue, 
with  thickening  of  the  overlying  pericardium  and  changes  in  the  arteries 
(endarteritis  obliterans).  The  fibrosis  may  represent  gummata  which 
have  undergone  absorption. 

Amyloid  degeneration  in  the  heart  is  very  rare,  but  a  few  cases  have 
been  recorded.  Endarteritis  obliterans  usually  occurs  in  association  with 
the  changes  of  fibrous  character.  The  symptoms  met  with  in  cases  of 
syphilitic  disease  of  the  heart  have  been  irregular  and  rapid  cardiac  action, 
palpitation,  dyspnoea,  precordial  pain  or  uneasiness,  angina  pectoris,  and 
attacks  of  syncope  or  epilepsy.  It  is  obvious  that  there  are  none  of  these 
symptoms  which  may  not  accompany  other  forms  of  cardiac  disease,  but 
the  occurrence  of  such  symptoms  in  early  adult  life  without  definite  cause, 


336  GENERAL  DISEASES. 

such  as  valvular  disease,  rheumatism,  or  excess  in  tobacco,  should  suggest  a 
suspicion  of  syphilis.  Syphilitic  disease  of  the  left  side  of  the  heart  may 
be  characterised  by  gradually  increasing  feebleness  without  dilatation ;  and 
similar  disease  on  the  right  side,  by  persistent  dyspnoea.  Hypertrophy  of 
the  heart  without  increased  power,  in  the  absence  of  obvious  cause,  suggests 
syphilis.  Sudden  death  is  not  infrequent.  This  occurred  in  eight  out  of 
fourteen  cases  collected  by  Duckworth ;  and  out  of  sixty-three  cases  collected 
by  Mracek,  it  occurred  in  twenty-one.  Other  observers  have  noted  sudden 
death  in  half  of  the  cases.  Eupture  of  the  heart  has  occasionally  occurred. 
At  other  times  death  occurs  with  symptoms  of  slowly  increasing  cardiac 
failure,  and  the  formation  of  cardiac  thrombus. 

If  specific  treatment  is  started  early,  the  prognosis  is  good ;  but  when 
the  disease  is  well  advanced,  no  improvement  from  iodide  of  potassium 
can  be  looked  for. 

The  arteries. — Syphilitic  arteritis  may  occur  during  the  first  year  of 
acquired  syphilis,  but  is  more  common  during  the  tertiary  period,  at  any 
time  up  to  twenty  years  after  the  primary  sore.  It  also  may  result  from 
inherited  syphilis,  then  occurring  before  the  tenth  year.  It  most  usually 
affects  the  cerebral  arteries,  especially  the  basilar,  the  middle  cerebral,  the 
vertebral,  the  internal  carotid,  and  the  posterior  cerebral.  Often  several 
branches  are  affected  simultaneously.  The  vessels  may  be  diseased  for 
from  \  to  1  in.  of  their  length,  and  generally  in  the  whole  of  their 
circumference.  Although  the  lesions  resemble  those  of  atheroma,  they 
differ  in  their  seat,  and  in  the  period  of  life  at  which  they  occur,  as 
well  as  in  their  course,  which  is  fairly  rapid.  In  this  lesion  it  is  the  inner 
coat  which  is  chiefly  affected.  The  intima  becomes  greatly  thickened,  and 
generally  asymmetrically  so.  The  space  between  the  endothelium  and  the 
membrana  fenestrata  becomes  occupied  by  a  finely  granular  substance,  a 
kind  of  ill-developed  connective  tissue,  containing  a  few  nuclei  and 
nucleated  spindle-shaped  and  stellate  cells.  The  growth  may  be  fibroid, 
hyaloid-looking,  or  caseous,  according  to  the  stage  of  the  disease.  The 
endothelium  becomes  thickened,  and  the  lumen  of  the  vessel  is  gradually 
encroached  on.  Small  round  cells  may  also  make  their  appearance  in  the 
middle  and  outer  coats.  Thrombosis  gradually  occurs,  as  the  lumen  of  the 
vessel  becomes  more  contracted. 

Another  variety  has  been  described  as  syphilitic  periarteritis.  In  this 
the  main  lesion  is  situated  in  the  tunica  adventitia,  and  is  of  a  gummatous 
nature.     Growths  of  a  considerable  size  may  form  in  this  situation. 

Respiratory  system.  —  The  nose.  —  Secondary  affections  of  the 
pituitary  membrane  are  relatively  not  very  common.  They  consist  of 
hyperemia,  superficial  ulcers,  mucous  patches,  and  redundant  adenoid  tissue, 
and  give  rise  to  symptoms  resembling  a  troublesome  catarrh.  Tertiary 
perforation  of  the  septum  is  not  infrequent.  When  the  vomer  is  affected, 
the  bridge  of  the  nose  may  fall  in,  producing  a  characteristic  flattening, 
while  the  tip  becomes  depressed  when  the  cartilage  is  destroyed.  In 
tertiary  lesions  the  discharge  is  generally  abundant,  and  very  offensive  when 
the  bone  is  carious. 

Larynx. — Statistics  show  that  the  larynx  is  affected  in  the  course  of 
syphilis  in  from  3  to  4  per  cent,  of  all  the  cases.  The  lesions  are  for  the 
most  part  slight,  and  are  of  a  serious  nature  in  not  more  than  a  ninth  or 
tenth  part  of  these  cases. 

Simple  catarrh  of  the  larynx  has  already  been  referred  to  as  not 
uncommon  during  the  early  secondary  period.     It  may  recur  or  come  on 


SYPHILIS.  337 

for  the  first  time  later.  There  is  nothing  characteristic  about  the  appear- 
ance of  the  larynx,  which  simply  shows  hyperemia  and  congestion. 
Mucous  patches,  condylomata,  and  limited  superficial  ulcerations  may  also 
occur  during  the  secondary  period,  but  are  much  less  common  than  simple 
catarrh.  In  tertiary  syphilis,  diffuse  infiltration,  gummata,  perichondritis, 
and  destructive  ulceration,  with  ensuing  cicatricial  contraction,  are  the 
principal  lesions  met  with.  Gummata  and  perichondritis  of  the  epiglottis 
and  arytenoids  are  not  uncommon.  The  perichondritis  results  in  caries 
and  necrosis  of  the  cartilage,  with  subsequent  separation  of  the  diseased 
part.  The  epiglottis,  or  the  arytenoids,  may  be  wholly  destroyed.  Ulcers 
are  usually  large,  deep,  sharply  limited,  and  have  a  worm-eaten  floor. 
They  are  often  unilateral  and  solitary.  Frequently  there  is  a  marked 
absence  of  pain,  although  there  may  be  a  considerable  amount  of 
dysphagia  when  the  epiglottis  is  much  affected.  Syphilitic  ulceration 
usually  progresses  rapidly.  The  lesions  are  surrounded  by  a  zone  of 
congestion  and  oedema.  The  upper  surface  of  the  epiglottis  is  more 
frequently  affected  than  the  lower.  The  ary-epiglottic  folds,  the  ventricular 
bands,  and  the  vocal  cords  are  not  uncommon  seats  of  ulceration.  Paralysis 
of  the  vocal  cords  may  result  either  from  local  syphilitic  disease,  or  from 
lesions  involving  the  nerves  or  their  nuclei.  Stenosis  of  the  glottis 
sometimes  follows  extensive  ulceration. 

The  diagnosis  has  to  be  made  from  tubercle  and  new  growth.  The 
hypersemic  appearance,  the  rapidity  of  progress,  and  the  extent  and 
destructive  character  of  the  ulceration,  probably  limited  to  one  side,  help 
to  distinguish  it  from  tubercle.  There  may  be  great  difficulty  in  differenti- 
ating syphilis  of  the  larynx  from  carcinoma.  Ulceration  proceeds  more 
rapidly  in  syphilis  than  in  carcinoma,  and  in  the  latter  the  growth  is 
often  nodular.  Pain,  foetor,  and  haemorrhage  are  much  more  frequent  in 
carcinoma  than  in  syphilis.  Enlargement  of  glands  is  in  favour  of 
carcinoma. 

The  prognosis  as  regards  life  is  not  unfavourable  when  treatment  is 
efficiently  carried  out.  The  most  serious  result  is  usually  stenosis,  for 
which  tracheotomy  may  be  necessary,  and  there  may  be  permanent  altera- 
tion or  even  loss  of  voice.  Barely,  acute  oedema  or  haemorrhage  may 
carry  the  patient  off. 

Local  treatment  is  rarely  called  for.  Insufflations  or  antiseptic  spraying 
may  be  necessary  in  the  case  of  necrosing  perichondritis,  or  of  foul  ulcera- 
tion. Stenosis  may  require  intubation  or  tracheotomy.  Dilatation  by 
Schrotter's  bougies  or  O'Dwyer's  tubes,  as  a  rule,  affords  only  temporary 
relief.     General  treatment  must  be  carried  out  on  the  usual  lines. 

Syphilis  of  the  trachea,  though  a  rare  affection,  is  of  considerable 
importance.  It  occurs  during  the  tertiary  period,  and  has  usually  been 
met  with  in  subjects  between  the  ages  of  25  and  50.  Persons  exposed 
to  irritating  dust  appear  specially  liable.  It  occasionally  occurs  in 
congenital  as  well  as  in  acquired  syphilis. 

Tracheal  syphilis  usually  occurs  in  the  form  of  gummatous  infiltration 
in  the  submucous  tissue,  and  may  be  unassociated  with  lesions  elsewhere 
in  the  respiratory  tract.  Its  most  usual  seat  is  the  anterior  surface  of  the 
lower  portion  of  the  trachea,  just  above  the  bifurcation.  The  gummata 
soften  and  ulcerate.  Multiple  perichondritis  is  readily  set  up,  and 
detached  portions  of  cartilage  may  project  into  the  trachea,  and  may  be 
separated  and  expectorated.  Ulceration  is  usually  followed  by  great 
cicatricial  contraction,  and  the  calibre  of  the  trachea  may  be  reduced  to 
VOL.  i. — 2  2 


338  GENERAL  DISEASES. 

that  of  a  crow-quill.  There  may  be  dilatation  above  and  below  the  annular 
stricture,  but  the  stenosis  involves  generally  a  considerable  portion  and 
sometimes  the  whole  length  of  the  tube.  While  the  ulcers,  as  a  rule,  heal, 
they  may  perforate  into  the  oesophagus,  superior  vena  cava,  aorta,  or  other 
neighbouring  part.  Adhesions  to  the  oesophagus  may  interfere  with  the 
upward  movements  in  deglutition. 

The  main  symptoms  are  inspiratory  stridor  and  dyspnoea.  The  dyspnoea 
will  vary  in  proportion  to  the  degree  of  stenosis.  Importance  was  at  one 
time  attached  to  absence  of  laryngeal  excursions  as  a  point  of  importance 
in  the  diagnosis  of  tracheal  stenosis,  but  later  experience  has  shown  that 
this  cannot  be  depended  on.  The  head  is  often  bent  forward,  instead  of 
being  thrown  back,  as  in  laryngeal  dyspnoea.  Cough  and  expectoration 
frequently  precede  the  dyspnoea.  There  may  be  attacks  of  paroxysmal 
dyspnoea,  from  the  accumulation  of  secretion  below  the  point  of  stricture ; 
and  the  diagnosis  between  aneurysm  compressing  the  trachea  and  syphilitic 
stenosis  may  be  by  no  means  easy.  The  voice  is  often  hoarse  or  croupy,  or 
it  may  be  simply  weak. 

Syphilis  of  the  bronchi. — A  few  cases  have  been  recorded  where  one  or 
both  main  bronchi  have  been  affected  with  syphilitic  stenosis  without  the 
trachea  being  involved,  but  it  is  more  common  for  the  disease  in  the 
bronchi  to  be  secondary  to,  or  accompanied  by,  disease  in  the  trachea. 
Rolleston  and  Ogle,  who  could  collect  only  ten  cases  in  literature  (Clin. 
Soc.  Trans.,  1899),  consider  that  when  both  bronchi  are  affected,  the  stenosis 
is  more  probably  part  of  a  diffuse  syphilitic  change,  often  also  involving 
the  lungs,  and  of  the  nature  of  a  peribronchitic  fibrosis,  than  a  primary 
syphilitic  lesion,  sharply  limited  to  the  main  bronchi,  and  due  to  the  pre- 
vious ulceration  of  gummata,  while  when  one  bronchus  is  affected  the 
stenosis  is  probably  the  result  of  the  cicatrisation  of  an  ulcer. 

The  symptoms  of  stenosis  of  both  bronchi  will  be  similar  to  those  of 
stenosis  of  the  trachea.  The  acute  onset  of  grave  symptoms  after  a  long 
period  of  latency  may  be  the  result,  as  Rolleston  and  Ogle  suggest,  of 
retained  secretion,  increased  in  amount  from  an  accidental  bronchial 
catarrh. 

Syphilis  of  the  lungs  is  a  very  rare  condition,  much  more  so  than  the 
similar  affection  of  the  trachea.  It  is  seldom  diagnosed  during  life.  More 
cases  are  met  with  in  men  than  in  women.  It  is  apparently  not  more 
common  in  those  affected  with  chronic  pulmonary  lesions  than  in  others, 
and  it  is  not  often  found  simultaneously  with  tuberculosis. 

There  are  two  forms  in  which  syphilis  is  met  with  in  the  lungs  in  cases 
of  acquired  syphilis.  These  are  gummata  and  disseminated  fibrosis  or 
induration.  The  two  forms  are  frequently  combined.  Mention  must  also 
be  made  of  a  form  of  consolidation  found  in  the  lungs  of  newly-born 
syphilitic  children.  It  is  seldom  that  an  opportunity  arises  of  seeing 
gummata  in  early  stages,     fibrosis  is  essentially  an  old  or  chronic  lesion. 

Gummata  are  frequently  combined  with  broncho-pneumonia.  They  are 
usually  few  in  number,  often  solitary,  and  rarely  are  there  more  than  six 
or  eight.  They  have  a  round  or  ovoid  form,  and  vary  in  size  from  a  pin's 
head  to  a  walnut  or  Tangerine  orange.  They  may  be  superficial  or  deeply 
situated,  and,  as  a  rule,  affect  only  one  lung.  They  are  not  usual  at  the 
apex,  but  more  commonly  are  situated  about  the  middle  or  lower  part  of 
the  upper  lobe  or  near  the  hilus.  They  have  a  greyish  white  colour,  and 
are  of  firm  consistence  externally,  although  tending  to  soften  at  the  centre. 
While  the  outer  part  consists  of  fibrous  tissue,  the  centre  probably  is  com- 


SYPHILIS. 


339 


posed  of  yellowish  detritus,  which  gradually  discharges  into  the  bronchi. 
Thus  cavities  as  large  as  the  original  gummata  may  arise,  surrounded  by  firm 
fibrous  walls.  The  cavities  may  persist  or  become  gradually  occluded  from 
contraction  of  their  walls.     The  centre  may  be  the  seat  of  calcareous  deposit. 

In  distinguishing  gummata  from  tubercles,  the  following  points  should  be 
considered — their  seat,  number,  colour  (which  is  white  or  yellow  and  never 
translucent),  and  consistence,  which  is  always  harder  and  more  resistant  than 
that  of  tubercle. 

Syphilitic  fibrosis  often  commences  round  the  medium-sized  bronchi  and 
the  bronchial  arteries  near  the  hilum,  whence  it  radiates  into  the  rest  of 
the  lung,  gradually  invading  the  alveoli  The  indurations  are  formed  by 
connective  tissue  of  the  embryonic  type,  which  replaces  the  pulmonary 
parenchyma.  Bronchiectasis  may  follow,  or  the  bronchi  may  be  more  or 
less  obliterated.  This  form  of  lesion  has  no  precise  seat.  It  may  occur 
indifferently  at  the  middle  or  at  the  base,  but  rarely  affects  the  apex. 
Ordinarily  it  is  bilateral,  and  it  may  be  circumscribed  or  diffuse.  The 
pleura  usually  takes  part  in  the  process,  the  two  layers  becoming  adherent 
and  thickened.  Syphilitic  fibrosis  is  difficult  to  distinguish  from  tuberculous, 
except  when  it  is  associated  with  gummata  or  unmistakable  syphilitic 
lesions  elsewhere. 

A  remarkable  condition  of  consolidation  has  been  observed  in  the  lungs 
of  newly-born  children  infected  with  syphilis.  The  lungs  are  distended 
so  as  to  fill  the  thoracic  cavity  completely,  and  are  marked  with  the 
impressions  of  the  ribs.  The  pleurae  as  a  rule  are  unaffected.  The 
whole  of  both  lungs  may  be  affected,  or  the  morbid  change  may  be 
partial.  The  consolidated  tissue  is  four  or  five  times  heavier  than  normal. 
On  section,  it  appears  white  with  a  shade  of  yellow,  and  the  cut  surface  is 
smooth  and  opaque. 

It  is  usually  dense  and  resistant,  but  may  be  friable.  The  whiteness  of 
the  structure  results  from  its  bloodlessness,  neither  blood  nor  smaller 
blood  vessels  being  present,  except  in  the  interlobular  tissue.  The  bronchial 
glands  are  enlarged  and  of  a  greyish  caseous  appearance.  According  to 
Wagner,  the  consolidation  results  from  a  thickening  of  the  walls  of  the 
alveoli  whereby  their  cavities  are  gradually  obliterated.  The  epithelium 
is  but  little  affected.  The  thickened  walls,  when  examined  microscopically, 
show  the  presence  of  an  imperfectly  fibrillated  tissue,  with  an  almost 
complete  obliteration  of  the  capillaries  and  small  vessels ;  the  interlobular 
tissue  may  be  normal.  When  the  consolidation  is  partial,  there  may  be 
isolated  patches  resembling  gummata.  Similar  changes  have  been  re- 
corded in  the  lungs  of  adults. 

There  is  nothing  pathognomonic  about  the  symptoms  of  syphilis  of  the 
lungs.  In  the  early  stages  the  symptoms  are  usually  those  of  laryngeal 
and  bronchial  catarrh  with  some  alterations  of  the  voice,  cough,  and  short- 
ness of  breath.  At  a  later  period  cough  is  more  troublesome,  and  dyspnoea 
becomes  more  marked.  Expectoration  at  first  is  usually  scanty  and  mucoid, 
but  later  is  probably  purulent,  and  may  be  offensive.  The  absence  of 
tubercle  bacilli  in  the  sputum  is  an  important  point,  but  fragments  of 
pulmonary  tissue  may  be  present.  Haemoptysis,  slight  in  some  cases, 
profuse  in  others,  is  not  infrequent.  The  dyspnoea  may  be  paroxysmal, 
coming  on  in  attacks  resembling  spasmodic  asthma,  and  associated  with 
pain  in  the  side.  Attacks  of  this  nature,  as  has  been  mentioned,  may  also 
be  met  with  when  the  trachea  alone  is  involved.  The  temperature  is  not 
usually  raised,  but  fever  has  been  a  feature  of  some  of  the  recorded  cases. 


34Q  GENERAL  DISEASES. 

Sometimes  the  patient  keeps  in  good  general  condition,  but  this  cannot  be 
said  to  be  the  rule.  Emaciation,  antenna,  and  marasmus  are  frequently 
observed.  The  physical  signs  met  with  are  those  of  consolidation  or  of 
excavation,  and  these  are  probably  observed  in  an  unusual  situation  for  a 
tuberculous  lesion.  Although  the  middle  portions  of  the  lungs  are  the  most 
likely  situations  in  which  to  find  abnormal  physical  signs,  the  apices  and 
bases  are  also  sometimes  affected. 

The  occurrence  of  symptoms  such  as  have  been  mentioned  in  a  patient 
with  a  history  of  syphilis,  or  with  syphilitic  lesions  or  traces  of  them  in 
other  parts  of  the  body,  would  probably  rightly  lead  to  a  diagnosis  of 
syphilitic  disease  of  lung.  We  may  suspect  syphilis,  in  the  absence  of 
confirmatory  evidence  of  the  disease,  in  cases  where  tuberculosis  can  be 
excluded  and  malignant  disease  is  unlikely.  A  trial  of  antisyphilitic 
treatment  is  always  necessary  to  complete  the  diagnosis.  It  should  be 
remembered  that  syphilis  and  tubercle  have  occasionally  been  met  with  in 
the  same  lung. 

Of  sixty-two  cases  collected  by  Carrier,  thirty-eight  died  and  twenty 
were  cured.  The  prognosis  is  good,  if  energetic  antisyphilitic  treatment  is 
adopted,  unless  the  pulmonary  lesions  are  associated  with  grave  disease  of 
the  other  viscera.  The  occurrence  of  albuminuria  appears  to  render  the 
prognosis  more  unfavourable.  Out  of  forty-four  fatal  cases  collected  by 
Pancritius,  in  twenty-seven  albuminuria  was  observed. 

Pleurisy  has  been  observed  during  the  secondary  stage,  or  quite  late 
in  the  disease.  It  may  occur  along  with  the  secondary  eruptions  with  the 
usual  symptoms.  It  may  be  dry  or  attended  with  moderate  effusion. 
Sometimes  there  is  a  severe  pain  in  the  side,  and  there  may  be  intense 
dyspncea  and  fever.     Pleurisy  is  often  accompanied  by  joint  affections. 

Gemto-urinary  organs.  — Renal  disease. — Small  gummata  are  occasion- 
ally observed  in  the  kidneys,  generally  in  association  with  gummata  in  the 
liver  or  elsewhere.  Very  rarely  a  gummatous  infiltration  may  produce  a 
large  renal  tumour.  Nephritis  occasionally  occurs  in  the  patients  who 
are,  or  have  been,  the  subjects  of  syphilis ;  but  it  is  doubtful  whether  such 
cases  are  specific.  Amyloid  disease  of  the  kidneys  is  sometimes  a  con- 
sequence of  syphilis. 

Testicle. — The  testicle  is  not  uncommonly  affected  in  the  early  tertiary 
stage.  There  is  a  painless  uniform  enlargement  of  the  body  of  the  organ. 
There  is  often  an  accompanying  hydrocele,  which,  as  a  rule,  is  not  consider- 
able. The  surface  of  the  organ  remains  quite  smooth,  although  in  a  few 
cases  small  masses  of  induration  may  be  felt  at  an  early  stage.  The 
epididymis  is  very  rarely  affected,  and  the  cord  remains  healthy.  The 
enlargement  is  often  considerable,  and  the  organ  may  reach  the  size  of  a 
man's  fist.  Hutchinson  remarks  that  when  the  tumour  is  large  it  feels 
very  light  in  the  hand,  but  this  feature  is  by  no  means  constant.  The 
smoothness  and  hardness  and  the  absence  of  pain  are  the  most  important 
points.     Both  organs  may  be  affected. 

The  nervous  system. — Frequency. — It  has  been  estimated  that  the 
brain  is  affected  in  from  12  to  21  per  cent,  of  patients  who  have  tertiary 
symptoms,  and  in  from  \\  to  2 \  per  cent,  of  all  infected  with  primary 
disease. 

Time  of  occurrence. — This  may  be  as  early  as  the  sixth  month,  or  as  late 
as  the  twentieth  year  from  infection.  The  first  year  has  more  cases 
than  subsequent  years,  the  number  gradually  diminishing  with  each  year. 
It  has  been  estimated  that  40  per  cent,  of  the  cases  of  cerebro-spinal  syphilis 


SYPHILIS.  341 

occur  within  two  years  of  infection.  Of  the  lesions  connected  with  occlu- 
sion of  vessels,  25  per  cent,  occur  during  the  first  two  years.  The  earliest 
case  observed  by  Gowers  happened  three  months  after  infection. 

Sex. — Men  are  more  frequently  affected  than  women,  as  they  are  with 
syphilis  in  general. 

Dissipation,  alcoholic  and  sexual  excesses,  anxiety,  mental  strain, 
injury  to  the  head,  together  with  the  inheritance  of  nervous  instability, 
predispose  to  a  cerebral  localisation  of  syphilis.  Early  efficient  mercurial 
treatment  probably  saves  many  from  cerebral  symptoms.  It  is  well  recog- 
nised that  the  nervous  system  is  relatively  more  frequently  affected  in 
slight  cases  which  have  passed  untreated. 

Following  Gowers,  we  may  classify  the  lesions  of  the  nervous  system 
produced  by  syphilis  as — Inflammatory  or  congestive ;  resulting  from  a 
process  of  tissue  formation ;  and  system  diseases. 

The  inflammatory  lesions  are  chiefly  meningeal,  with  hyperplasia  as 
their  characteristic  feature.  Much  new  tissue,  with  a  gelatinous  appear- 
ance, is  produced,  which  may  either  become  fibrous  or  caseate.  Either  the 
external  or  the  internal  membrane  may  be  affected.  Pachymeningitis 
is  more  common  in  the  inherited  form  than  in  the  acquired.  In  the  pia 
mater  the  inflammation  is  usually  local,  and  the  new  tissue  is  abundant. 
In  the  spinal  cord  the  pia  mater  is  seldom  affected  alone.  The  meningitis 
is  frequently  cerebro-spinal.  Inflammation  of  the  substance  of  the  brain 
occurs  very  early,  but  a  case  of  chronic  disseminated  inflammation  has 
been  described  by  Charcot  and  Gombault.  The  nerves,  especially  the 
cranial  nerves,  may  be  the  seat  of  syphilitic  inflammation,  in  which  case 
there  is  cellular  growth  and  infiltration  of  leucocytes  in  the  sheath  and 
interstitial  tissue.  The  optic  nerves  and  the  motor  nerves  of  the  eyes 
are  specially  prone  to  neuritis.  Cases  of  polyneuritis  and  neuritis  of 
individual  nerves,  such  as  the  ulnar,  have  been  recorded.  The  nerves  may 
also  be  affected  in  meningeal  lesions,  or  they  may  be  compressed  by  swell- 
ing in  bony  foramina,  by  aneurysms  of  syphilitic  origin,  or  by  gummata. 
Syphilis,  moreover,  predisposes  to  degeneration  of  the  nuclei  of  the  nerves. 

A  form  of  disseminated  subacute  myelitis,  in  which  defined  islets  of 
inflammation  occupy  the  white  substance  of  the  cord,  especially  near  the 
surface,  has  been  described  by  Julliard  and  Perret. 

Under  the  heading  of  lesions  resulting  from  a  process  of  tissue 
formation,  must  first  be  mentioned  the  occlusion  of  cerebral  arteries  by 
syphilitic  disease.  The  large  vessels  at  the  base  are  those  most  frequently 
affected,  and  their  occlusion  leads  to  extensive  softening  of  the  cerebral 
tissue. 

Gummata  grow  commonly  from  the  pia  mater,  and  compress  and 
invade  the  substance  of  the  brain  or  cord.  They  are  rare  within  the  sub- 
stance of  the  brain  or  on  the  cranial  nerves,  although  cases  have  been 
recorded  in  which  they  were  symmetrically  situated  on  the  latter.  The 
dura  mater  is  generally  adherent  to  the  tumour,  and  a  diffuse  form  of 
gumma  is  sometimes  met  with  growing  from  this  membrane.  Giunmata 
are  generally  superficial  in  the  cerebral  hemispheres  or  the  pons.  They 
seldom  invade  the  cerebellum  or  corpus  striatum,  but  occasionally  the 
growth  finds  its  way  beneath  the  optic  thalamus,  spreading  by  extension 
from  the  crus. 

It  is  unnecessary  to  repeat  the  description  which  has  been  given  of  the 
morbid  anatomy  of  a  gumma  generally.  The  irregularity  of  shape  and  of 
caseation  helps  to  distinguish  it  from  tubercle.     "While  the  gumma  does 


342  GENERAL  DISEASES. 

not  infiltrate  the  neighbouring  brain  substance,  it  produces  softening  and 
displacement. 

The  symptoms  are  like  those  of  any  other  tumour,  and  are  general  and 
local.  The  course  of  the  malady  is  subacute  or  subchronic ;  and  cerebral 
symptoms  of  very  long  duration  are  not  likely  to  be  produced  by 
syphilis.  Optic  neuritis,  when  present,  is  always  acute,  and  may  be 
intense.  A  chronic  form  of  optic  neuritis  is  opposed  to  a  diagnosis  of 
syphilitic  growth.  The  seat  of  the  gumma  being  superficial,  symptoms  of 
cortical  irritation  are  more  frequent  than  in  the  case  of  other  tumours. 
Convulsions  are  common.  The  oculomotor  nerves  are  frequently  involved, 
or  there  may  be  affection  of  smell  or  hearing. 

The  relations  of  tabes  and  general  paralysis  to  syphilis  must  be  left 
for  discussion  elsewhere ;  but  there  appears  to  be  a  large  amount  of  evi- 
dence as  to  the  causal  relations  of  syphilis  with  these  affections. 

Occlusion  of  vessels  produces  a  sudden  focal  lesion.  Hemiplegia  is  the 
most  common  effect.  This  may  be  slight  and  transitory,  or  severe  and 
permanent.  The  onset  of  complete  occlusion  is  seldom  attended  by  loss 
of  consciousness.  It  is  often  preceded  by  headache,  which  may  last  for  a 
few  days,  weeks,  or  months.  The  pain  may  be  severe,  and  it  may  be  general, 
or  limited  to  the  site  of  the  lesion.  When  the  basilar  artery  is  occluded, 
there  is  very  profound  nervous  disturbance,  with  coma,  bulbar  symtoms, 
bilateral  paralysis,  and  rapid  rise  of  temperature. 

The  headache  of  cerebral  syphilis  has  certain  peculiarities,  which  may 
be  briefly  enumerated.  The  pain  is  deeply  seated,  and  constrictive  or 
hammering.  It  may  be  localised  or  diffused,  but  is  seldom  general  over 
the  whole  head.  Its  characteristics  are  its  intensity,  its  nocturnal  exacer- 
bations, and  its  long  duration  and  relapses.  Nocturnal  exacerbations  may, 
however,  be  conspicuous  by  their  absence.  Insomnia  is  a  frequent  symptom, 
and  when  associated  with  headache  should  excite  a  suspicion  of  syphilis. 

Epileptic  attacks  are  common  symptoms.  They  possess  in  themselves 
no  special  diagnostic  features,  and  their  syphilitic  origin  is  generally  borne 
out  by  the  history  and  the  association  with  other  symptoms  not  usually 
present  in  ordinary  epilepsy. 

The  symptoms  produced  by  chronic  syphilitic  meningitis  indicate  a 
surface  lesion.     There  are  no  signs  of  any  considerable  loss  of  function. 

Hutchinson  has  called  attention  to  cases  in  which  myelitis  appears  to 
attack  the  lower  part  of  the  spinal  cord  during  the  secondary  stage 
of  syphilis.  Gowers  points  out  that  syphilitic  lesions  of  vessels  so  small 
as  those  of  the  spinal  cord  are  unknown.  The  myelitis  is  probably  pro- 
duced by  the  toxine  of  syphilis.  A  temporary  condition  of  paraplegia, 
affecting  the  sphincters  as  well  as  both  sensation  and  motion  in  the  lower 
extremities,  may  ensue.  The  upper  extremities  are  usually  unaffected.  It 
is  generally  amenable  to  vigorous  treatment,  and  does  not  relapse.  Para- 
plegia may  occur  during  the  tertiary  period,  from  various  causes,  such  as 
gummata,  etc. 

There  are  two  important  elements  in  the  diagnosis  of  cerebral 
syphilis,  which  have  been  emphasised  by  Gowers — first,  the  course  of  the 
symptoms ;  and,  second,  the  probable  seat  of  the  lesion  or  lesions.  As 
regards  the  course,  true  specific  lesions  are  generally  subacute  or  sub- 
chronic.  Symptoms  of  certainly  specific  lesions  rarely  develop  to  a  con- 
siderable degree  in  less  than  a  week.  On  the  other  hand,  they  are  very 
seldom  actually  chronic,  and  do  not  often  take  longer  than  three  months  to 
develop.     An  actually  sudden  onset  is  not  at  all  uncommon,  and  is  the 


SYPHILIS.  343 

usual  event  in  vascular  occlusion.  When  symptoms  come  to  a  climax  in  a 
few  clays,  or  take  many  months  to  develop,  it  is  not  likely  that  they  are  due 
to  a  specific  lesion.  Important  help  may  also  be  derived  from  a  knowledge 
of  the  usual  seat  of  syphilitic  lesions.  Syphilitic  processes  being  outside 
the  nerve  elements,  have  no  special  relation  to  nerve  function.  Hence  their 
effects  are  random  in  their  distribution,  and  are  only  related  to  special 
function,  when  that  function  is  subserved  by  one  region. 

The  diagnosis  of  occlusion  of  vessels  is  assisted  by  the  consideration  that 
such  symptoms  as  are  present  are  seldom  produced  before  the  age  of  45, 
except  from  embolism.  Embolism  is  extremely  unlikely  in  the  absence  of 
valvular  disease  of  the  heart.  After  the  age  of  45  the  difficulties  of 
diagnosis  are  greatly  increased,  for  we  have  to  consider  the  possibilities  of 
occlusion  from  atheroma,  etc. 

The  diagnosis  of  syphilitic  paraplegia  must  be  effected  from  the  history 
and  the  presence  of  other  signs  of  syphilis. 

The  results  of  treatment  may  confirm  the  diagnosis.  There  should  be 
considerable  diminution  in  the  symptoms  within  from  six  to  ten  weeks,  as  far 
as  these  are  directly  due  to  specific  processes.  Treatment,  however,  can  have 
no  effect  on  such  lesions  as  are  due  to  blocking  of  vessels,  or  when  nerve 
elements  have  been  destroyed  by  the  contraction  of  new  fibrous  tissue. 

The  prognosis  is  best  in  the  case  of  gummata,  and  worst  in  the  case 
of  occlusion  of  vessels.  According  to  the  estimate  of  Mickle,  about  50 
per  cent,  of  the  cases  recover  more  or  less  completely;  probably  from  25 
to  35  per  cent,  die,  and  the  remainder  survive  with  grave  nervous  disorder. 
Hutchinson  has  recently  stated  that  in  his  experience  paraplegia,  as 
occurring  during  the  first  two  years  of  syphilis,  is  nearly  always  recovered 
from,  and  never  relapses,  and  that,  as  regards  patients  affected  with  hemi- 
plegia, they  nearly  all  recover  their  health  although  permanently  hemiplegia 

Life  assurance  in  relation  to  syphilis. — The  practice  of  life 
assurance  offices  varies  considerably  in  regard  to  the  acceptance  of 
lives  in  which  there  is  a  history  of  syphilis.  Jonathan  Hutchinson, 
at  a  discussion  at  the  Life  Assurance  Medical  Officers'  Association  in 
1896  on  this  subject,  stated  his  opinion  that,  on  the  whole,  the  extra  risk 
in  cases  of  syphilis,  in  otherwise  healthy  persons,  was  a  very  slight  one.  In 
the  case  of  a  man  with  a  primary  sore  who  was  in  good  health,  and  likely 
to  submit  to  judicious  treatment,  he  considered  that  there  were  no  extra- 
ordinary risks  to  be  run.  In  the  secondary  period,  unless  the  case  was 
quite  exceptional,  he  would  not  consider  the  expectation  of  life  to  be  below 
the  average.  The  practice,  however,  with  most  offices,  is  to  postpone  any 
case  in  which  there  are  signs  of  active  syphilis,  and  to  add  an  extra  of  from 
three  to  seven  years  in  cases  in  which  there  is  a  history  of  primary  syphilis 
during  the  five  years  preceding  the  proposal. 

Prophylaxis. — The  best  prophylactic  is  chastity.  The  danger  of 
contracting  syphilis  can  be  greatly  diminished  by  personal  cleanliness, 
and  the  systematic  use  of  soap,  warm  water,  and  antiseptics,  together 
with  vaginal  douches  in  the  case  of  the  female.  That  cleanliness  alone  is 
by  no  means  a  certain  preventive,  is  shown  by  the  frequent  occurrence 
of  syphilis  in  the  higher  grades  of  society.  The  spread  of  syphilis  is 
undoubtedly  promoted  among  the  lower  classes  by  neglect  of  personal 
cleanliness  in  both  sexes.  Every  person  who  has  syphilis  in  an  active 
form  should  be  warned  as  to  the  dangers  of  inoculating  another  person  with 
the  disease. 

Marriage  in  relation  to  syphilis. — If  an  infected  person  has  been  for  a 


344  GENERAL  DISEASES. 

period  of  at  least  two  years  without  symptoms  of  any  kind,  he  may  be 
permitted  to  marry.  The  risk  that  he  will  communicate  syphilis  to  his 
wife,  or  to  his  offspring,  after  that  period,  is  extremely  small. 

Treatment. — There  are  two  drugs  whose  action  on  syphilis  and  its 
lesions  is  specific.  These  are  mercury  and  iodide  of  potassium,  the  first 
being  specially  valuable  in  the  earlier,  the  second  in  the  later  stages.  We 
shall  consider  the  treatment  in  the  primary  stage  and  in  the  secondary  and 
tertiary  stages  separately. 

The  primary  stage. — The  excision  of  the  chancre  was  recommended  by 
Hiiter,  Auspitz,  and  Unna.  We  have  seen  that  the  vessels  and  lymphatics 
in  connection  with  the  chancre  are  involved  at  a  very  early  period,  and, 
accordingly,  removal  of  the  chancre  cannot  arrest  the  disease.  I  agree 
with  E.  W.  Taylor  in  believing  that  no  single  case  of  syphilis  was  ever 
aborted  or  annihilated  by  early  surgical  procedure  of  any  kind. 

The  presence  of  a  chancre  always  indicates  the  necessity  for  local  clean- 
liness. The  parts  should  be  frequently  washed  with  warm  water  containing 
a  drachm  of  boric  acid  to  the  pint,  or  mercurial  washes  may  be  employed, 
such  as  solution  of  corrosive  sublimate  (1  in  2000),  or  black  or  yellow 
wash,  or  solution  of  sulphate  of  zinc  (2  grs.  to  the  oz.).  Should  the  sore 
become  angry,  iodoform  powder  may  be  locally  applied. 

There  is  a  wide  diversity  of  opinion  as  to  the  advisability  of  adminis- 
tering mercury  at  this  stage.  Many  authorities  consider,  and  with  these 
we  agree,  that  where  there  is  an  undoubted  indurated  chancre,  mercurial 
treatment  should  be  immediately  commenced.  Taylor  holds  that  early 
treatment  with  mercury  only  delays  the  appearance  of  secondary  manifesta- 
tions for  a  longer  or  shorter  time,  and,  as  a  rule,  does  not  lessen  the  severity 
or  extent  of  their  distribution,  and  in  many  cases  seems  to  render  them  more 
severe.  He  is  convinced  that  it  is  by  far  the  best  plan  to  wait  until  the 
onset  of  the  secondary  stage  before  beginning  a  mercurial  course.  Jonathan 
Hutchinson,  on  the  other  hand,  is  of  opinion  that  it  is  quite  possible,  by 
the  early  and  continuous  use  of  mercury,  to  suppress  the  secondary  stage, 
or,  in  other  words,  to  make  it  abortive.  He  states  that  in  exceedingly  few 
cases,  where  it  has  been  possible  to  use  mercury  without  interruption  from 
an  early  period,  has  he  known  a  well-characterised  secondary  eruption  or  a 
typical  sore  throat  to  occur.  All  are  agreed  that  when  the  local]  condition 
is  troublesome,  attended  by  indurating  oedema,  etc.,  mercury  should  be 
started  at  once.  There  is  no  doubt,  however,  that,  as  a  general  rule,  before 
mercurial  treatment  is  started  it  is  of  the  greatest  importance  to  be  certain 
of  the  diagnosis.  The  absence  of  secondary  symptoms  is  not  an  unmixed 
good,  if,  as  the  result,  the  medical  attendant  or  the  patient  is  left  in  doubt 
as  to  the  nature  of  the  malady.  As  Taylor  remarks,  it  is  most  salutary 
for  the  syphilitic  to  be  convinced  beyond  any  doubt  that  he  is  syphilitic. 
In  the  case  of  a  sore  the  nature  of  which  is  doubtful,  mercurial  treatment 
should  be  reserved  for  the  appearance  of  the  secondary  stage. 

It  is  important  at  an  early  stage  that  the  patient  should  be  put  into  a 
proper  condition  for  a  course  of  mercury.  A  careful  general  examination 
of  the  patient  should  be  made,  so  that  the  practitioner  may  have  a  thorough 
knowledge  of  his  constitution  and  general  state  of  health.  The  teeth  should 
be  inspected,  and  any  that  are  carious  appropriately  treated.  Smoking  should 
be  prohibited  and  moderation  in  alcohol  enjoined.  Sexual  intercourse,  it  is 
needless  to  say,  must  be  forbidden,  as  long  as  there  is  any  risk  to  be  run 
by  the  second  party.  The  condition  of  the  skin  may  be  improved  by  a 
course  of  Turkish  baths. 


SYPHILIS. 


345 


The  secondary  and  tertiary  periods. — All  authorities  admit  the  need 
for  mercury  during  the  secondary  period,  but  opinions  differ  as  to  dosage, 
mode  of  administration,  and  duration  of  treatment.  There  are  four  methods 
in  which  mercury  may  be  used — internal  administration,  inunction,  fumi- 
gation, and  hypodermic  injection.  The  remedy  may  be  given  only  when 
symptoms  are  present ;  or  at  intervals  over  several  years ;  or  continuously, 
for  six  months  or  several  years. 

The  plan  of  giving  mercurials  only  during  the  period  when  syphilitic 
symptoms  show  themselves,  was  recommended  by  Diday.  Unfortunately 
one  sees  only  too  frequently  how  inefficient  such  treatment  is.  In  spite  of 
repeated  warnings,  hospital  patients  often  only  submit  themselves  to  treat- 
ment while  there  are  active  symptoms.  It  is  in  these  cases  that  one  sees 
the  worst  forms  of  syphilis. 

The  interrupted  mode  of  treatment  was  introduced  by  Fournier.  The 
patient  is  treated  with  mercurials  for  two  months,  and  then  goes  a  month 
without.  He  is  again  treated  with  mercurials  for  two  months,  has  three 
months'  respite,  and  again  has  two  months'  treatment,  followed  by  three 
months'  respite,  symptoms  or  no  symptoms.  In  two  years  the  patient  has 
ten  months  with  and  fourteen  months  without  treatment.  In  the  third 
and  fourth  years  the  patient  has  four  courses  of  treatment  lasting  six 
weeks,  with  intervals  of  equal  duration.  In  the  fifth  year  three  courses 
are  given.  The  preparation  of  mercury  preferred  by  Fournier  is  the  green 
iodide,  which  may  be  given  in  divided  doses  amounting  to  f  to  \\  gr. 
daily. 

The  short  continuous  treatment  was  that  pursued  by  Eicord,  who 
recommended  active  treatment  with  mercury  for  six  months,  followed  by 
iodide  of  potassium  for  three  months  longer. 

The  prolonged  continuous  treatment  is  that  which  has  the  support  of 
Hutchinson  in  this  country  and  Keyes  in  America,  and  is  carried  out  by  a 
large  number  of  practitioners.  Hutchinson  uses  small  doses  of  grey  powder ; 
Keyes,  the  green  iodide.  Hutchinson  recommends  1  gr.  doses  in  pill, 
in  combination  with  opium  (gr.  \  or  ^),  repeated  as  frequently  as  the 
patient  can  bear  it ;  the  problem  being  to  introduce  as  much  mercury  as 
possible  without  producing  salivation  or  diarrhoea.  Salivation  must  be 
guarded  against  by  hygiene  of  the  teeth  and  the  use  of  an  alum  mouth- 
wash, while  diarrhoea  must  be  prevented  by  appropriate  diet  and  small 
doses  of  opium.  The  1  gr.  pill  may  be  taken  four,  five,  six,  or  even 
seven  times  a  day,  without  reference  to  meals. 

Keyes  recommends  that,  to  commence  with,  a  granule  (\  gr.)  of  the 
green  iodide  should  be  given  three  times  a  day.  The  dose  should  be 
gradually  increased  to  four,  five,  six,  etc.,  granules  a  day,  until  a  dose  is 
reached  when  the  gums  become  slightly  affected  or  diarrhoea  sets  in.  This 
daily  dose  should  not  be  exceeded,  and  may  be  continued  with  the  aid  of 
opiates  and  unirritating  food,  until  active  symptoms  have  disappeared, 
when  the  dose  may  be  reduced  to  half,  but  should  be  at  once  increased 
if  symptoms  again  appear. 

Blue  pill  in  doses  of  1  to  3  grs.,  the  tannate  or  gallate  of  mercury  in 
doses  of  half  a  grain,  and  the  biniodide  in  doses  of  TV  to  \  gr.,  are  the  most 
usual  preparations  of  mercury  given  by  the  mouth,  in  addition  to  the  grey 
powder  and  the  green  iodide  already  mentioned.  Corrosive  sublimate  in 
the  form  of  the  liquor  (dose,  1  drm.)  is  frequently  given  in  combination 
with  iodide  of  potassium  in  the  later  stages. 

Iodide  of  potassium  is  as  valuable  in  the  period  of  periosteal  nodes, 


346  GENERAL  DISEASES. 

tertiary  eruptions,  and  gummata,  as  mercury  is  in  the  earlier  periods.  It 
may  be  administered  in  doses  of  from  3  to  20  grs.  three  times  a  day,  either 
with  or  without  mercury.  It  is  not,  as  a  rule,  indicated  in  the  secondary 
stage,  but  even  then  should  be  given  if  cerebral  complications  arise. 

Individual  cases  of  syphilis  must  be  treated  according  to  their  special 
features ;  and  while  ordinary  mild  cases  may  do  exceedingly  well  on  the 
continuous  treatment  with  small  doses  given  by  the  mouth,  cases  will  every 
now  and  then  be  met  with  which  call  for  other  measures.  Thus,  when 
mercury  by  the  mouth  upsets  the  stomach  or  causes  diarrhoea,  then 
inunction,  fumigation,  etc.,  may  be  adopted  with  advantage. 

The  method  of  inunction  is  preferred  to  that  of  internal  administration 
by  many  practitioners  of  great  experience,  as  being  more  active,  certain, 
and  speedy  in  its  effects.  The  blue  ointment  is  the  favourite  application. 
It  should  be  freshly  made.  The  amount  used  at  each  application  should 
be  from  40  to  50  grs.  It  should  be  well  rubbed  in,  the  process  taking 
about  half  an  hour.  The  part  rubbed  should  be  changed  daily,  so  that 
every  part  of  the  body  in  turn  has  its  share  of  the  application.  The 
inunction  should  be  preceded  by  a  bath,  and  if  a  professional  rubber  can  be 
obtained,  it  is  better.  If  the  patient  is  occupied  during  the  day,  the  appli- 
cation should  be  made  in  the  evening,  otherwise  the  morning  is  the  best 
time.  Oleate  of  mercury  has  also  been  used  for  inunction,  in  strengths 
varying  between  5  and  20  per  cent.,  but  has  not,  on  the  whole,  proved  so 
suitable  as  the  blue  ointment.  Lately,  mercurial  soaps  have  been  employed. 
A  lather  is  made  with  these,  which  is  applied,  and  allowed  to  dry  on  the 
skin. 

Fumigation  is  another  means  of  obtaining  the  rapid  action  of  mercury, 
and  may  be  used  in  obstinate  and  severe  cases  with  advantage.  Twenty 
to  forty  grs.  of  calomel  or  cinnabar  are  put  in  a  small  vessel  suspended 
over  the  flame  of  a  small  lamp,  and,  together  with  a  pan  of  boiling  water, 
are  placed  under  a  chair,  on  which  the  patient  sits  covered  with  blankets. 
The  duration  of  the  bath  should  be  from  twenty  to  thirty  minutes.  It 
may  be  taken  every  other  day,  just  before  bed-time. 

The  principal  forms  of  hypodermic  intramuscular  and  intravenous 
injections  are  suspensions  of  calomel  or  yellow  oxide  of  mercmy,  and 
solutions  of  corrosive  sublimate.  The  method  is  one  which  cannot  be 
recommended  for  routine  use,  and  must  be  considered  a  measure  to  be 
used  in  cases  of  emergency,  such  as  ocular,  aural,  and  cerebral  syphilis. 
Pure  calomel  is  administered  in  1  gr.  doses,  suspended  in  10  minims  of  pure 
glycerin,  glycerin  and  water,  or  mucilage  of  acacia,  or  in  combination  with  1 
gr.  of  sodium  chloride  and  10  minims  of  water.  Calomel  injections  are  gener- 
ally painful,  and  often  give  rise  to  abscesses  and  troublesome  subcutaneous 
lesions.  The  yellow  oxide  of  mercury  is  given  in  2  gr.  doses,  suspended 
with  half  a  gr.  of  acacia  in  60  minims  of  water.  It  is  said  to  be  less  pain- 
ful and  less  frequently  followed  by  local  lesions  than  calomel.  Perchloride 
of  mercury  is  given  hypodermically  in  doses  of  a  tenth  to  an  eighth  of  a 
grain  dissolved  in  ten  or  twelve  drops  of  water.  All  these  injections  should 
be  made  deeply  into  the  subcutaneous  tissue  and  not  into  the  cutis  vera. 
Necrosis  of  the  skin  is  likely  to  follow  if  the  injections  are  too  superficial. 
The  best  situation  for  injections  is  the  subcutaneous  tissue  of  the  buttocks, 
especially  the  depressions  behind  the  great  trochanters.  The  injections 
may  be  made  every  second  day.  The  treatment  is  not  well  borne  by 
women  and  children.  The  perchloride  injections  are,  on  the  whole,  the 
most  satisfactory,  and  are  valuable  where  a  prompt  action  is  desired.    They 


SYPHILIS.  347 

are  rarely  followed  by  abscesses.  Pain  at  the  seat  of  injection,  infiltration, 
and  local  erythema  are  the  most  serious  consequences.  Great  care  should 
always  be  exercised  that  the  injections  are  given  with  the  strictest  anti- 
septic precautions. 

Intramuscular  injections  of  the  double  chloride  of  mercury  and  am- 
monia (sal  alembroth)  have  been  highly  spoken  of  by  some  surgeons  in 
this  country,  especially  Bloxam.  A  solution  is  used,  containing  2  grs.  of 
perchloride  of  mercury  and  1  gr.  of  chloride  of  ammonium  in  1  drm.  of 
water.  Ten  minims  of  this  solution  are  injected  deeply  into  the  gluteus 
maxinms  muscle  once  a  week.  Intravenous  injections  were  introduced 
by  Baccelli,  who  employed  solutions  of  perchloride.  This  method  has 
been  largely  used  by  continental  surgeons,  but  not  much  in  this  country. 
Chopping  speaks  very  favourably  of  the  use  of  a  1  per  cent,  solution  of 
the  cyanide  of  mercury,  of  which  20  minims  are  introduced  into  the 
vein  of  the  forearm  in  the  direction  of  the  blood  stream.  A  rubber 
tourniquet  is  kept  applied  to  the  upper  part  of  the  arm  until  the  needle 
has  entered  the  vein,  when  it  is  removed  and  the  injection  then  made. 
The  injection  is  repeated  daily.  Those  who  have  employed  the  method 
maintain  that  it  brings  about  a  more  rapid  and  certain  cure  than  any 
other  plan  of  treatment. 

Serum  treatment. — Of  late  years  treatment  by  means  of  injections  of 
serum,  obtained  from  an  individual  previously  affected  by  the  disease,  has 
been  tried,  and  some  have  obtained  good  results,  both  in  the  primary  lesion 
and  in  secondary  syphilis.  The  serum  from  an  individual  with  well-marked 
secondary  syphilis  has  been  found  to  have  more  powerful  antitoxic  pro- 
perties than  one  from  an  individual  with  tertiary  symptoms.  The  serum 
of  horses,  mercurialised  previous  to  bleeding,  has  also  been  tried,  but  has 
not  been  found  to  be  beneficial,  if  it  is  not  positively  harmful. 

Whatever  mode  of  treatment  is  employed,  an  endeavour  should  be 
made  to  keep  up  the  patient's  general  health.  Good  food,  early  hours,  fresh 
air,  and  change  of  air  and  scene,  are  all-important  aids  in  treatment.  In 
chronic  cases,  an  occasional  course  at  Aix-la-Chapelle  will  prove  of  service. 
A  sea-voyage,  or  bracing  sea-air,  will  greatly  benefit  where  there  is  much 
debility. 

Hereditary  syphilis,  as  a  rule,  requires  prolonged  and  active  treatment. 
A  pregnant  woman  should  be  actively  treated,  not  only  when  she  is  herself 
syphilitic,  but  also  when  the  father  of  her  child  is  syphilitic,  although  she 
herself  may  manifest  no  signs  of  the  disease.  Inunction  and  hypodermic 
injections  of  mercurial  preparations,  as  already  described,  are  more  effective 
than  other  methods  when  the  mother  is  syphilitic,  but  when  the  mother 
is  healthy  small  continuous  doses  should  be  given  In  any  case  the  treat- 
ment should  be  commenced  soon  after  the  onset  of  pregnancy,  and  should 
be  continued  during  its  whole  duration.  The  same  treatment  may  be  carried 
out  during  lactation.  Both  mercury  and  iodide  of  potassium  have  been 
found  in  the  milk,  when  these  drugs  are  administered  to  the  mother.  Grey 
powder  is  the  most  suitable  form  of  administration  of  mercury  to  infants. 
It  may  be  given  in  doses  of  one-eighth  to  one-third  of  a  grain  three  times  a 
day.  The  green  iodide  of  mercury  is  also  a  useful  preparation.  To  com- 
mence with,  one-twentieth  of  a  grain  may  be  given,  and  the  dose  may  be 
gradually  increased  to  a  quarter  of  a  grain.  Corrosive  sublimate  is  also  a 
favourite  preparation  with  some  authorities.  Inunctions  may  be  used  with 
benefit  in  later  stages.  In  the  more  severe  cases  of  hereditary  syphilis, 
even  minute  doses  of  mercury  sometimes  seem  to  hasten  the  fatal  end.    In 


348  GENERAL  DISEASES. 

these,  mercury  must  be  given  with  the  greatest  caution,  and  the  feeding  of 
the  child  must  be  seen  to  with  the  greatest  care. 

HECTOR  MACKENZIE. 


TUBEECULOSIS. 


A  specific  parasitic  disease  caused  by  a  definite  micro-organism,  the  B. 
tuberculosis,  and  characterised  anatomically  by  the  presence  of  minute  bodies 
called  tubercles,  which  tend  to  coalesce,  to  caseate,  to  soften,  or  to  undergo 
fibrous  or  calcareous  changes.  The  disease  may  be  local,  and  limited  to  one 
organ  or  tissue,  or  it  may  be  generally  disseminated  throughout  the  body. 

The  disease  is  always  due  to  infection,  directly  or  indirectly,  from  pre- 
existing cases,  either  in  man  or  the  lower  animals.  It  is  not  always  itself 
infectious.  It  only  becomes  certainly  infectious  when  there  is  a  com- 
munication between  the  diseased  part  and  the  exterior  of  the  body,  through 
winch  the  infective  material  may  be  discharged. 

History. — Tuberculosis  is  by  far  the  most  important  disease  to  which 
the  human  race  is  subject.  It  attacks  a  third,  or,  as  some  have  estimated, 
half  the  population  of  European  countries,  and  kills  a  sixth  part  of  the 
whole  race.  It  prevails  in  almost  every  part  of  the  world,  among  all  races 
and  all  conditions  of  men.  It  exists  to  a  wide  extent  among  domesticated 
animals,  and  in  some  of  these  proves  as  fatal  as  it  is  in  man.  It  invades 
every  organ  and  every  tissue  of  the  body,  but  has  a  special  affinity  for  the 
respiratory  tract.  Through  the  latter  the  micro-organisms  most  usually 
invade  the  body.  In  the  lungs  they  multiply,  set  up  fresh  colonies,  and 
from  thence  are  discharged  from  the  body  by  expectoration,  and,  thus  set 
free,  are  again  able  to  enter  a  fresh  host. 

In  its  pulmonary  form  the  malady  was  known  to  the  ancients,  and  was 
described  by  Hippocrates.  The  name  of  phthisis  was  given  to  it,  on 
account  of  the  wasting  of  the  body  which  was  observed  to  be  the  usual 
result  of  the  disease.  A  graphic  description  of  the  physiognomy  of  the 
patient  in  an  advanced  stage  of  the  disease  was  given  by  Aretaeus,  and 
could  be  little  improved  on  in  the  present  day.  It  was  observed  that  the 
wasting  of  the  body  was  accompanied  by  wasting  of  the  lungs.  It  was  not 
until  the  seventeenth  and  eighteenth  centuries  that  any  useful  knowledge 
of  the  anatomical  changes  met  with  in  phthisis  was  acquired,  and  that 
the  small  round  bodies  found  in  the  lesions  began  to  be  described  as 
tubercles.  Matthew  Baillie,  in  1793,  gave  a  clear  description  of  tubercles — 
"  Eounded  firm  white  bodies,  at  first  very  small,  not  larger  than  the  heads 
of  very  small  pins,  and  in  this  case  frequently  accumulated  in  small 
clusters.  The  small  tubercles  of  a  cluster  grow  together  and  form  one 
larger  cluster."  The  caseation  of  these  bodies,  the  softening  of  their  centres, 
and  finally  the  formation  of  abscesses  and  cavities  in  the  lungs,  were  accur- 
ately observed.  The  relation  of  caseous  tubercle  in  the  lung  to  caseous 
tumours  in  the  neck  and  elsewhere,  which  were  designated  scrofula,  began 
to  be  discussed. 

The  great  advances  in  a  knowledge  of  the  disease  date  from  the  nine- 
teenth century.  Three  men  deserving  of  special  honour  stand  out  from 
all  others  who  have  laboured  in  this  field.  These  are  Laennec,  Villemin, 
and  Koch.  Laennec  (1819)  taught  the  unity  of  tubercle  in  its  various 
forms  and  situations,  and,  by  the  discovery  of  auscultation,  made  it  possible 


TUBER  C  UL  OSIS.  349 

to  detect  the  presence  of  the  lesions  set  up  in  the  lungs  by  tubercle,  as  had 
never  been  the  case  before.  Villemin  (1865)  proved  the  inoculability  of 
tubercle  on  the  lower  animals  ;  and  finally  Robert  Koch  (1882)  announced 
the  discovery  of  the  B.  tuberculosis,  and  by  masterly  methods  proved  the 
bacillus  to  be  the  cause  of  the  disease,  and  demonstrated  the  unity  of  all  the 
various  forms  of  tuberculosis.  Thus  the  local  form  of  tubercle,  which  was 
for  a  long  time  thought  to  be  a  distinct  malady,  and  was  described  under 
the  name  of  scrofula,  and  phthisis  which  was  regarded  as  typically  a  con- 
stitutional disease,  the  result  of  a  diathesis,  were  both  seen  to  be  simply 
different  forms  of  the  same  disease. 

Predisposing  causes. — Constitution. — It  has  been  a  belief  handed 
down  from  the  time  of  Hippocrates,  that  certain  constitutional  peculiarities 
render  individuals  more  susceptible  to  phthisis.  A  clear,  delicate  skin, 
pink  and  white  complexion,  fine  silky  hair,  long  eyelashes,  bright  eyes, 
tapering  fingers,  and  precocity  of  intellect,  are  some  of  the  general  charac- 
teristics which  have  been  thought  to  point  to  vulnerability  to  tuber- 
culosis. Landouzy  has  recently  revived  the  idea  that  individuals  with  red 
hair,  with  blue  eyes  and  fair  skin,  are  specially  liable  to  tubercle.  Such 
persons  he  euphemistically  calls  "  Venetians."  Certain  peculiarities  in  the 
shape  of  the  chest  have  been  also  associated  with  phthisis.  In  a  typical 
form  the  upper  ribs  are  straight,  and  their  interspaces  widened,  the  lower 
ribs  oblique,  and  their  interspaces  narrowed,  the  whole  chest  being  long 
and  narrow,  and  flat  from  before  backwards.  The  clavicles,  too,  are  pro- 
minent at  their  acromial  ends,  while  the  scapulae  project  like  wings.  In 
other  cases,  the  chest  is  long,  narrow,  and  rounded,  and  the  diaphragm 
relatively  high.  These  types  of  chest  are  perhaps  more  often  the  results 
of  the  disease  than  its  predisposing  causes.  Lanky  overgrown  young 
adults  often  fall  a  prey  to  tubercle,  but  perfect  physique  appears  to  form 
no  barrier  to  its  development. 

Sex. — The  influence  of  sex  has  been  variously  estimated  by  different 
observers.  Laennec  and  other  authorities  since  his  time  have  stated  that 
women  are  more  subject  than  men  to  pulmonary  tuberculosis.  The 
general  experience  in  London  is  that  the  reverse  is  the  case,  and  more 
men  than  women  suffer  from  the  disease.  Thus,  out  of  1562  out-patients 
under  my  care  at  the  Brompton  Hospital,  affected  with  pulmonary 
tuberculosis,  904  were  males  and  658  females,  giving  a  proportion  of  100 
males  to  73  females.  This  proportion  tallies  closely  with  that  of  male 
and  female  deaths  from  pulmonary  tuberculosis,  as  given  in  the  Registrar- 
General's  reports.  The  mean  annual  death-rate  in  a  standard  million 
from  phthisis,  1881-90,  was  in  London,  for  males,  2247,  and  for  females, 
1580.  For  the  whole  of  England  and  Wales  during  the  same  period  the 
rate  was  1847  males  to  1609  females.  This  shows  that  for  the  whole 
country  more  males  than  females  are  affected  by  pulmonary  tuberculosis. 

The  remarks  of  Tatham  on  this  point  are  of  great  interest  and 
importance.  He  says :  "  From  the  year  1851  to  1865  the  phthisis  rate 
was  greater  among  females  than  among  males,  although  the  difference 
gradually  diminished  as  time  went  on.  Ever  since  the  year  1866,  however, 
the  mortality  has  been  uniformly  in  excess,  not  among  females  as  formerly, 
but  among  males ;  and  in  the  last  two  decennia  the  excess  of  the  male-rate 
over  the  female-rate  was  greater  than  had  been  the  excess  of  the  female- 
rate  in  the  decennium  1851-60.  From  information  obtained  since  1890,  it 
has  been  ascertained  that  a  similar  change  in  the  sex-incidence  of  phthisis 
mortality  is  still  going  on."     Thus,  while  the  female-rate  to  the  male-rate, 


35° 


GENERAL  DISEASES. 


taken  as  1000,  in  1851-60  was  1076,  in  1861-70  it  was  1006,  in  1871-80, 
918,  and  in  1881-90,  871.  "  In  the  decennium,  1881-90,  in  twenty-four 
counties,  containing  more  than  three-fourths  of  the  entire  population  of 
England  and  Wales,  the  male  death-rates  were  in  excess  of  the  female, 
while  in  the  remaining  twenty-one  counties,  containing  less  than  one- 
fourth  of  the  population,  the  female-rates  were  in  excess  of  the  male- 
rates."  "  As  in  the  case  of  phthisis,"  Tatham  adds,  "  the  mortality  from 
other  tuberculous  diseases  is  considerably  higher  among  males  than  among 
females." 

Age. — Tuberculosis  manifests  itself  at  all  ages.  In  the  young  it  tends 
to  affect  the  glands,  or  to  distribute  itself  widely  throughout  the  body ; 
in  the  adolescent  or  adult  it  more  commonly  locates  itself  in  the  lungs  in 
the  form  of  chronic  pulmonary  phthisis.  The  greatest  prevalence  of 
phthisis  is  in  the  adult,  between  the  ages  of  20  and  45,  while 
other  forms    of   tuberculosis  nourish   most  widely  in   children   under  5. 

Annual  Mortality  per  Million  living  at  all  Ages,  and  at  Eleven  Groups  of 
Ages  in  Three  Decennia. 


75 

All 

Ages. 

0- 

5- 

10- 

15- 

20- 

25- 

35- 

45- 

55- 

65- 

and 

Up- 

wards 

Phthisis. 

1861-70  -\ 

r 

2475 

96S 

454 

825 

2651 

3928 

4243 

4026 

3340 

2656 

1603 

539 

1871-80    l 

Persons       X 

2116 

767 

358 

664 

2036 

3117 

3619 

3745 

3132 

2449 

1476 

492 

1881-90  J 

[ 

1724 

536 

290 

521 

1545 

2324 

2901 

3132 

2737 

2169 

1355 

521 

Other  Tuberculous  Diseases. 

1861-70  -s 

r 

765 

4477 

525 

269 

182 

125 

90 

76 

88 

111 

121 

78 

1871-80    l 

Persons       -[ 

747 

4442 

503 

256 

169 

104 

74 

62 

65 

80 

96 

45 

1881-90  J 

[ 

696 

3963 

554 

306 

229 

171 

128 

107 

94 

94 

83 

48 

For  males,  the  largest  rate  of  mortality  from  phthisis  exists  between  the 
ages  35  and  45,  and  for  females  between  25  and  35.  In  the  case  of 
other  tuberculous  diseases,  by  far  the  heaviest  mortality  is  found  under 
the  age  of  5.,  from  which  period  it  gradually  diminishes.  It  is  popularly 
supposed  that  the  liability  to  pulmonary  tuberculosis  diminishes  with  age, 
and  that  it  is  seldom  contracted  after  50.  The  tables  which  we  give  from 
the  Eegistrar-General's  Eeports  "show  the  prevalence  of  the  disease  in  late 
as  well  as  early  life. 

Heredity. — Tuberculosis  is  pre-eminently  considered  to  be  a  hereditary 
disease.  It  has  been  shown  over  and  over  again  that  a  larger  proportion 
of  cases  of  tuberculosis  occurs  among  the  children  of  phthisical  parents 
than  among  the  offspring  of  the  non-phthisical. 

The  experience  of  all  life  assurance  companies  has  been  that  among 
those  with  a  family  history  of  phthisis  there  is  a  heavier  mortality  than 
the  normal.  To  protect  themselves  from  loss,  it  is  usual  to  charge  extra 
premiums  in  such  cases.     The  record  of  eighty  families  with  hereditary 


TUBERCULOSIS.  351 

history  was  investigated  with  great  care  by  Eeginald  Thompson.  Out  of 
385  children,  more  than  half  were  affected  with  tuberculosis.  Out  of 
11,041  cases  of  phthisis,  collected  by  various  investigators,  there  were 
3084  in  which  one  or  both  parents  were  phthisical,  giving  a  proportion 
of  nearly  28  per  cent.  Out  of  1205  cases  under  my  own  care,  one 
or  both  parents  were  phthisical  in  342,  giving  a  proportion  of  28-4. 
Of  course,  if  one  includes  brothers,  sisters,  uncles,  aunts,  etc.,  the  pro- 
portion of  so-called  hereditary  cases  will  be  still  further  increased,  and 
it  may  be  safely  asserted  that,  in  over  a  quarter  of  the  cases  of  tubercu- 
losis, there  will  be  found  a  history  of  tubercle  in  the  parents,  and  in  a 
half  of  the  cases  in  some  member  of  the  family. 

It  has  been  found  that  a  larger  proportion  of  women  than  of  men  in 
London  have  a  family  history  of  phthisis.  Thus,  out  of  515  women  under 
my  care,  one  or  both  parents  were  phthisical  in  180,  or  35  per  cent. ; 
wThile  in  690  males,  one  or  both  parents  were  phthisical  in  162,  or  in 
2 3 '5  per  cent.  Squire  similarly  found,  in  396  phthisical  females,  3 7 "9  per 
cent,  with  a  history  of  phthisis  in  parents,  and  in  604  males,  29  per  cent. 
Eeginald  Thompson,  including  collaterals  as  well  as  ancestors,  found  a 
family  history  in  58  per  cent,  of  females,  and  in  36  per  cent,  of  males. 
It  will  be  found  that,  when  one  takes  into  account  the  greater  prevalence 
of  phthisis  among  males  in  London,  that  a  family  history  is  found  in 
reality  in  quite  as  many  males  as  females. 

When  we  come  to  consider  what  is  the  meaning  of  heredity  in  phthisis, 
we  here  come  on  difficult  and  debatable  ground.  Before  the  knowledge  of 
the  dependence  of  the  disease  on  a  micro-organism,  it  was  considered  that 
the  disease  itself  or  a  diathesis  was  actually  inherited.  It  is  now 
generally  thought  that  what  is  inherited  is  not  the  disease  itself,  but  a 
predisposition  to  it.  In  the  case  of  the  child  of  a  phthisical  parent,  it  is 
obvious  that  the  chance  of  infection  is  very  considerable.  In  the  case 
where  phthisis  has  occurred  in  a  brother  or  a  sister,  the  chance  of 
exposure  to  a  common  cause  of  infection  must  be  borne  in  mind. 
Baumgarten  is  almost  alone  in  maintaining  not  only  that  the  disease  itself 
may  be  congenital,  but  that  it  generally  is  so.  A  large  number  of 
experiments  have  been  made  to  determine  whether  tuberculosis  might 
exist  in  a  latent  form  in  the  newly  born,  in  cases  where  there  was  no 
naked-eye  evidence  of  tubercle.  Fragments  of  the  organs  of  the  offspring 
of  tuberculous  mothers  have  been  inoculated  into  guinea-pigs.  In  only 
three  cases  have  the  experiments  proved  successful.  A  few  undoubted 
cases  have  recently  been  observed  where  women  in  an  advanced  stage  of 
tuberculosis  have  given  birth  to  tuberculous  foetuses,  or  infants  which  died 
soon  after  birth.  In  these  cases  both  tubercles  and  bacilli  have  been 
found  in  the  foetal  tissues,  while  bacilli  have  been  discovered  at  the  same 
time  in  the  placenta  and  in  the  blood  of  the  umbilical  vein.  Bang  of 
Copenhagen,  in  a  very  few  cases  out  of  a  large  number  examined,  has  found 
tubercle  in  the  internal  organs  of  the  foetuses  of  cows.  MTadyean,  of  the 
Eoyal  Veterinary  College,  London,  stated  in  1899  that  he  had  seen  only 
four  undoubted  cases  of  congenital  tuberculosis  in  the  calf,  although  he 
offered  a  premium  for  every  case  sent  to  him.  It  may  therefore  be 
accepted  that  foetal  tuberculosis,  though  possible,  is  an  extremely  rare 
event,  and  that  the  disease,  in  all  but  very  exceptional  cases,  is  acquired 
after  birth.  Everyone  will  admit  that  the  children  of  tuberculous  parents, 
especially  among  the  poor,  run  a  greater  risk  than  others  of  acquiring 
the  disease.     What  looks  like  heredity  is  often  simply  infection.    It  would 


352  GENERAL  DISEASES. 

appear  from  C.  T.  Williams'  experience  of  phthisis  among  the  higher 
classes,  that,  as  one  would  expect,  heredity  in  them  plays  a  smaller  part. 
He  found  direct  inheritance  in  120  out  of  1000  cases,  or  in  only  12  per 
cent.  Consanguinity,  where  both  parents  are  of  healthy  stock,  can  have 
no  effect,  but  where  on  both  sides  predisposition  exists  this  will  be  increased 
in  the  offspring. 

Trauma  has  been  recognised  as  a  predisposing  cause  of  tuberculosis. 
An  injury  to  a  joint  or  to  a  lung  may  be  followed  by  tubercle.  It  would 
seem  that,  as  the  result  of  the  injury,  the  part  was  able  to  offer  less 
resistance  to  the  tubercle  bacillus.  Perroud  has  described  a  form  of 
phthisis  affecting  boatmen  on  the  Ehone,  who,  from  constant  strain, 
sustain  a  kind  of  chronic  trauma  of  the  lung.  Mendelssohn  has  reported 
cases  of  phthisis  as  a  sequel  to  contusion  of  the  chest.  Operations  on 
tuberculous  joints  seem  sometimes  to  set  up  a  general  tuberculosis, 
probably  due  to  the  bacilli  gaining  entrance  to  the  circulation  through 
wounded  vessels. 

Occupation. — The  lower  classes  suffer  more  than  the  upper,  which  is 
explained  by  the  different  conditions  under  which  they  live,  apart 
altogether  from  occupation.  Those  who  lead  outdoor  lives  are  less  liable 
than  those  who  work  indoors.  Those  who  work  in  stuffy,  crowded 
rooms,  and  those  who  work  amid  dust,  such  as  grinders,  masons,  stone- 
cutters, workers  in  hair,  etc.,  are  the  most  liable. 

Environment. — Crowded,  dirty,  and  badly-ventilated  dwellings  must 
be  considered  as  particularly  potent  in  propagating  the  disease. 

Alcoholism  must  be  regarded  as  a  powerful  predisposing  cause  of 
tuberculosis.  It  is  almost  invariable  to  find  tubercle  present  in  the  lungs 
in  patients  dying  in  the  course  of  alcoholic  paralysis.  Tubercle  of  the 
peritoneum  or  pleura  frequently  complicates  cirrhosis  of  the  liver.  I 
have  found  a  history  of  alcoholic  excess  in  a  considerable  proportion  of 
my  male  phthisical  cases.  Dickinson,  in  comparing  a  number  of  alcoholic 
cases  with  a  like  number  in  which  there  was  no  history  of  drink,  found  a 
decidedly  larger  proportion  of  the  former  tuberculous.  It  would,  indeed, 
be  strange  if  it  were  otherwise.  Alcohol  in  excess  undermines  the 
strongest  constitution,  and  renders  the  body  less  resistant  to  disease  of 
all  kinds.  This  is  specially  true  when  the  individual  leads  a  sedentary 
town  life.  Considerable  amounts  of  alcohol  may  be  taken,  without  obvious 
deterioration  of  health,  by  persons  who  lead  an  out-of-door  life  and  eat 
heartily. 

Pregnancy  has  been  held  by  some  to  retard  the  progress  of  pulmonary 
tuberculosis,  by  others  to  increase  its  risks  and  hasten  the  fatal  termina- 
tion. The  evidence  of  different  authorities  has  been  fully  detailed  by 
Wilson  Fox,  who  concludes  that  phthisis  frequently  originates  during 
pregnancy,  and  that,  when  previously  existing,  it  is  aggravated  by  this 
state.  Its  course  is  often  accelerated  after  parturition,  although  in  some 
cases  the  symptoms  are  materially  alleviated. 

Previous  disease. — Diabetes  mellitus  is  frequently  complicated  with 
pulmonary  tuberculosis.  Such  cases  are,  however,  very  rarely  seen  at  the 
Brompton  Hospital.  Cancer  is  not  very  commonly  met  with  among  the 
tuberculous,  probably  for  the  reason  that  the  age-incidence  is  at  a  different 
period  of  life,  and  not  that  there  is  any  actual  antagonism  between  them. 
In  persons  dying  from  cancer,  a  tuberculous  lesion  in  the  lungs  is  frequently 
met  with.  Syphilis,  by  undermining  the  constitution,  increases  the  suscepti- 
bility to  tuberculosis.     Tuberculosis  in  a  syphilitic  subject  usually  runs  an 


TUBER  C  UL  OSIS.  353 

unfavourable  course.  Pleurisy  is  generally  considered  as  a  predisposing 
cause,  but  we  shall  see  that  what  is  regarded  as  simple  pleurisy  is  very 
frequently  tuberculous,  and  therefore  the  occurrence  of  pleurisy  is  often 
only  a  manifestation  that  tubercle  has  already  invaded  the  body.  Chronic 
bronchitis  not  uncommonly  appears  to  terminate  in  phthisis,  but  the  question 
then  sometimes  arises  whether  tubercle  has  not  been  present  all  along. 
Pneumonia  is  but  rarely  followed  by  phthisis.  Congenital  heart  disease  is 
very  often  complicated  with  pulmonary  tuberculosis.  This  is  especially 
likely  in  pulmonary  stenosis,  in  which  tubercle  of  the  lungs  is  a  frequent 
termination.  The  lower  vitality  produced  by  the  specific  fevers  must  be 
regarded  as  a  predisposing  cause.  Measles  in  children  is  especially  apt  to 
be  followed  by  tubercle. 

Other  predisposing  causes  are  prolonged  lactation,  insufficiency  of 
food,  and  depressing  moral  emotions,  which  appear  to  render  the  body 
less  resistant  to  bacilli. 

Antagonism. — Certain  diseases  or  morbid  conditions  are  believed  to 
exert  an  action  antagonistic  to  tuberculosis.  Of  these,  malaria  is  one  of 
the  most  important.  It  is  very  doubtful  whether  such  antagonism  really 
exists.  In  malarious  districts,  tuberculosis  is  constantly  mistaken  for 
malaria.  The  comparative  immunity  from  tuberculosis  which  has  been 
recorded  in  such  has  probably  depended  on  other  causes.  Mitral  stenosis 
is  only  exceptionally  associated  with  tubercle,  but  it  is  not  clear  that  other 
forms  of  valvular  disease  are  unfavourable  to  tubercle.  Asthma  and  em- 
physema are  also  believed  to  be  antagonistic  to  it.  This  is  probably  true 
as  regards  asthma,  but  emphysema  frequently  coexists  with  pulmonary 
tuberculosis.  Chlorosis,  plumbism,  gout,  and  rheumatism  are  other  condi- 
tions which  are  supposed  to  increase  the  resistance.  Chlorosis  and 
plumbism  probably  have  no  influence  one  way  or  the  other.  Gout  and 
phthisis  are  seldom  associated,  but  probably  for  the  reason  that  the  age 
incidence  is  different.  Rheumatism  certainly  does  not  diminish  the 
susceptibility  to  phthisis.  A  history  of  preceding  rheumatism  has  been 
observed  in  from  10  to  18  per  cent,  of  cases  of  phthisis. 

Bacteriology. — Character  of  bacilli. — The  bacilli  of  tubercle  are 
short  slender  rods  with  rounded  ends,  measuring  a  quarter  to  half  the 
diameter  of  a  red  blood  corpuscle,  l-5  /a  to  3-5  /a.  Their  apparent  breadth  is 
constant  for  the  same  method  of  staining,  varying  between  03  /j,  and  05  p. 
As  a  rule  they  are  slightly  curved.  They  are  usually  solitary,  but  occasionally 
occur  in  pairs,  or  in  short  chains  of  three  or  four  elements.  The  length  of 
the  bacillus  varies  with  the  culture.  Thus  the  rods  are  shorter  in  young 
cultures  than  in  old.  Frequently  the  bacilli  do  not  stain  uniformly,  but 
present  a  beaded  appearance,  due  to  the  occurrence  at  regular  intervals  of 
ovoid,  strongly  refracting  clear  spaces,  unaffected  by  the  colouring  agents. 
These  clear  spaces  were  considered  by  Koch,  who  first  observed  them,  to  be 
occupied  by  spores,  the  spores  resisting  the  stain  which  coloured  the  general 
protoplasm  of  the  bacillus.  The  prevailing  opinion  at  the  present  time  is 
that  they  are  not  spores  but  simply  vacuoles,  due  to  retrogressive  changes. 
Some  observers  have  found  spheroidal  bodies  to  be  present,  which  stain  more 
deeply  and  are  more  resistant  to  decolorisation  than  the  rest  of  the  bacillus. 
It  has  not  as  yet  been  successfully  demonstrated  that  these  bodies  possess 
the  biological  characteristics  of  spores. 

A  description  of  the  form  of  the  bacillus  would  be  incomplete  without 
some  reference  to  the  variations  which  have  been  observed  by  Metchnikoff, 
Pischel,  Coppen  Jones,  and  others,  in  old  cultures  and  in  cultures  grown 

VOL.  I. — 23 


354  GENERAL  DISEASES. 

in  special  media.  Metchnikoff  has  drawn  attention  to  certain  dwarf 
forms,  occurring  in  cultures  grown  on  serum  or  on  glycerin  jelly.  These 
are  extremely  short  bacilli,  closely  resembling  micrococci.  He  has  also 
found  in  avian  cultures  produced  at  a  temperature  of  43° -6  C.  giant  and 
ramifying  forms.  These  are  many  times  longer  than  the  ordinary  bacilli, 
and  are  clubbed  at  their  extremities.  In  the  older  cultures  branches  are 
thrown  out  from  the  body  of  the  bacillus,  which  similarly  are  club-shaped. 
Such  forms  have  almost  exclusively  been  found  in  cultures  of  avian 
tubercle,  but  Fischel  and  Bruns  have  observed  the  ramified  forms  also  in 
the  case  of  the  mammalian  bacillus.  Fischel  has  also  noted  filament-like 
forms,  with  short  lateral  branches  and  sometimes  forked  extremities. 
Lubinski  has  described  the  formation  in  certain  media  of  long  threads. 
The  existence  of  these  exceptional  forms  suggests  a  possible  relationship 
between  the  tubercle  bacillus  and  cladothrix,  or,  as  Coppen  Jones  thinks, 
between  it  and  the  ray  fungus. 

Staining  of  bacilli. — One  of  the  most  essential  characteristics  of  the 
bacillus  is  the  mode  in  which  it  reacts  to  staining  reagents.  It  is  stained 
by  aniline  dyes,  such  as  fuchsine  or  methyl- violet,  aided  by  a  mordant,  such 
as  aniline  oil  or  carbolic  acid,  and  resists  decolorising  by  dilute  acids.  This 
property  of  resistance  to  decolorising  serves  to  distinguish  it  from  all  other 
bacilli  known  to  produce  disease,  except  that  of  leprosy.  The  leprosy 
bacillus  is  stained  much  more  readily  and  rapidly  than  the  tubercle  bacillus, 
which  latter  stains  slowly,  or  requires  the  aid  of  heat  to  hasten  the  process. 
The  mode  in  which  the  leprosy  bacillus  is  grouped  in  clusters  in  the  interior 
of  special  cells  also  distinguishes  it  from  the  tubercle  bacillus.  It  resists 
better  than  the  tubercle  bacillus  the  decolorising  action  of  hypochlorite  of 
sodium.  The  smegma  bacillus  closely  resembles  the  tubercle  bacillus,  but 
is  much  more  readily  decolorised  after  staining.  Further  particulars  regard- 
ing it  are  given  in  the  section  on  renal  and  vesical  tuberculosis.  Eecently 
L.  Eabinowitsch  has  discovered  a  bacillus  which  is  very  frequently  present 
in  butter,  and  is  similar  both  morphologically  and  in  its  staining  reactions 
to  the  tubercle  bacillus.  It  differs  from  it,  however,  in  its  cultural  pro- 
perties, and  in  the  lesions  produced  on  inoculation,  which  more  resemble 
those  of  glanders  than  those  of  tuberculosis.  Although  pathogenic  for 
guinea-pigs,  it  is  not  pathogenic  for  rabbits  or  mice,  and  infected  animals 
do  not  react  to  tuberculin.  The  bacillus  recently  found  by  Moller  on 
timothy  and  other  grasses,  and  in  the  faeces  of  cows,  horses,  swine,  goats, 
and  mules,  also  closely  resembles  both  the  tubercle  bacillus  and  the  butter 
bacillus.     It  has  not  been  shown  that  these  bacilli  are  pathogenic  to  man. 

The  interval  which  elapsed  between  the  discovery  of  the  bacillus  of 
anthrax  and  that  of  tuberculosis  showed  that  there  must  be  some  special 
difficulties  in  staining  the  latter.  The  aniline  dyes  methylene-blue  and 
methyl-violet  had  been  found  to  stain  all  micro-organisms,  so  far  known, 
without  difficulty ;  but  until  applied  in  a  special  way  by  Koch,  they  did 
not  stain  the  B.  tuberculosis.  Koch  had  observed  that  the  addition  of  alkali 
to  methylene-blue  facilitated  the  coloration  of  various  micro-organisms, 
and  in  this  way  succeeded  in  staining  the  tubercle  bacillus,  and  rendering 
it  visible  for  the  first  time.  The  process  of  staining  was  greatly  improved 
and  simplified  by  Ehrlich,  who  showed  that  the  combination  of  an  aqueous 
solution  of  aniline  oil  with  an  aniline  dye,  such  as  methyl-violet,  formed  a 
fluid  which  stained  the  bacillus,  and  that  the  bacillus  so  stained  resisted 
decolorising  by  means  of  dilute  acid. 

Various  attempts  have  been  made  to  explain  the  cause  of  the  difficulty 


TUBERCULOSIS.  355 

of  staining  the  bacillus.  It  was  supposed  that  it  depended  on  the  presence 
of  an  envelope  which  was  naturally  very  resistant  to  the  stain,  and  that 
this  envelope  was  altered  by  an  alkali  or  aniline  oil  so  as  to  admit  the  stain 
to  the  interior.  The  envelope  similarly  prevented  the  penetration  of  the 
decolorising  acid  to  the  interior.  The  existence  of  an  envelope  endowed 
with  special  characteristics  is  a  pure  hypothesis.  Later  investigations  have 
shown  that  the  B.  tuberculosis  differs  from  others  as  regards  staining  only  in 
the  greater  difficulty  with  which  it  takes  the  stain,  and  the  corresponding 
difficulty  with  which  the  stain  can  be  removed. 

A  great  many  modifications  have  been  made  in  the  method  of  stain- 
ing,  which    has    thereby  been    much    simplified.      Aniline  reds,  such  as 
fuchsin  or  rubin,  have  been  found  more  practically  useful  than  methyl- 
violet.     One  of  the  most  convenient  methods  of  staining  is  that  of  Ziehl, 
as  modified  by  JSTeelsen.      The  staining  fluid  employed  is  composed  as 
follows : — 

Fuchsin  .  .  .  .  .  .  lgr. 

Phenol  .......  5gr. 

Distilled  water        .  lOOgr. 

Absolute  alcohol     .....         10gr. 

In  examining  sputum  for  bacilli,  a  small  yellow  mass  should  be  picked 
out  by  means  of  a  platinum  needle.  This  should  be  placed  between  two 
cover-glasses,  and  evenly  distributed  over  their  surfaces  by  slight  pressure. 
The  cover-glasses  are  then  separated.  The  films  are  allowed  to  dry,  and 
the  glasses  are  then  passed  two  or  three  times  through  the  flame  of  a  spirit- 
lamp  to  fix  the  films.  The  staining  fluid  may  then  be  poured  on  the  cover- 
glass,  or  the  latter  may  be  placed  face  down  on  the  surface  of  the  fluid.  In 
either  case,  heat  should  be  gently  applied  until  the  fluid  steams.  Staining 
is  effected  in  four  minutes  when  the  fluid  is  heated,  but  takes  considerably 
longer  at  ordinary  temperatures.  The  cover-glass  is  then  washed  with 
water.  Next,  to  decolorise  it,  it  is  placed  for  a  minute  or  two  in  a  25  per 
cent,  solution  of  sulphuric  acid  or  nitric  acid.  It  is  then  washed  in  dilute 
alcohol  to  remove  the  fuchsine  set  free  by  the  acid.  The  bacilli  are  then 
alone  left  coloured.  A  weak  solution  of  methylene-blue  may  be  used  as  a 
counter-stain,  and  when  washed  again  in  water,  the  preparation  is  ready 
for  examination.  The  staining  of  bacilli  in  the  tissues  is  a  more  difficult 
matter.  In  this  case  it  is  better  to  avoid  heating,  to  use  the  staining  fluid 
cold,  and  to  allow  it  to  act  for  twelve  to  twenty-four  hours. 

Natural  history  of  the  bacilli. — The  biology  of  the  bacillus  is  of  even 
greater  importance  than  its  morphology.  The  principal  biological  characters 
of  the  B.  tuberculosis  are  that  it  is  parasitic,  aerobic,  and  non-motile,  growing 
most  readily  at  a  temperature  of  about  37°  C.  It  is  a  facultative  anaerobic, 
and  probably  also  a  facultative  saprophyte.  From  an  etiological  point  of 
view  it  is  of  the  highest  consequence  to  know  under  what  conditions,  on  the 
one  hand,  the  bacillus  will  grow,  multiply,  and  flourish ;  and,  on  the  other, 
what  influences  will  check  or  destroy  its  vegetability  or  alter  its  virulence. 
The  organism  which  it  was  found  difficult  to  stain  was  also  found  difficult 
to  cultivate.  In  order  to  establish  the  role  which  the  bacillus  plays  in  the 
causation  of  the  disease,  it  was  necessary  to  obtain  pure  cultivations  in  some 
medium  outside  the  body,  and  to  show  that  such  pure  cultivations  were  able, 
equally  with  tuberculous  products,  to  produce  tuberculosis.  After  several 
failures,  Koch  succeeded  in  growing  the  bacillus  in  sterilised  blood  serum. 

It  was  found  to  develop  best  at  a  temperature  of  37°  to  38°  C. 
At  a  temperature  over  42°  it  ceased  to  grow.     At  30°  the  growth  was 


356  GENERAL  DISEASES. 

extremely  attenuated,  and  was  completely  arrested  between  28°  and  29°. 
A  point  of  extreme  practical  importance  is  that  the  bacillus  is  usually  in- 
capable of  growing  outside  the  body,  except  in  artificial  media  kept  at 
suitable  temperatures.  Solidified  blood  serum,  glycerin  agar  (nutrient  agar 
with  6  to  8  per  cent,  glycerin),  and  glycerin  meat  bouillon  (such  as  veal 
broth  with  5  per  cent,  of  glycerin),  are  found  to  be  the  best  media.  It 
has  also  been  successfully  cultivated  on  potato  and  other  vegetable  media. 
It  should  be  added  that  the  most  recent  investigations  go  to  show  that  the 
bacillus  can  live  outside  the  animal  body  on  dead  organic  matter.  There 
is  evidence  that  it  may  multiply  in  sputum  outside  the  body.  Del^pine 
states  that  colonies  of  the  mammalian  bacillus  will  grow  slowly  in  glycer- 
inated  media  at  the  ordinary  room  temperature,  both  summer  and  winter, 
without  losing  their  virulence.  Eansome  affirms  that  it  is  possible  to  grow 
the  bacillus  on  wall-paper  saturated  with  organic  vapour  from  the  breath 
at  the  ordinary  room  temperature. 

The  growth  of  the  bacilli  in  blood  serum  is  very  slow.  Except  when 
the  medium  has  been  contaminated,  no  change  occurs  until  one  or  two 
weeks  after  sowing.  At  the  end  of  this  interval  little  roundish  granules 
of  a  dull  white  colour  appear  on  the  surface.  These  increase  in  volume, 
and  at  the  end  of  another  week  become  slightly  prominent,  and  form  dry, 
dull,  greyish  white  scales.  In  the  first  cultures  the  scales  generally  remain 
isolated.  Second  and  third  cultures  are  prepared  in  the  same  way.  It  is 
not  until  the  fourth  or  fifth  generation  that  the  cultures  grow  more  rapidly, 
regularly,  and  abundantly,  having  become,  so  to  speak,  acclimatised  to  the 
media.  Subsequent  cultures  are  not  composed  simply  of  isolated  scales 
but  of  confluent  colonies.  All  the  surface  is  covered  with  a  thin,  dry  layer, 
studded  with  little  prominences.  The  bacilli  in  multiplying  do  not  develop 
in  depth,  but  always  at  the  surface.  They  never  liquefy  the  serum,  and 
always  remain  superficial.  The  liquid  at  the  bottom  of  the  tube  is  never 
rendered  cloudy,  even  when  fragments  of  the  growth  are  detached  and 
inserted  in  that  position. 

At  the  end  of  a  month  the  cultures  have  generally  acquired  their 
maximum  of  development.  The  appearances  of  cultures,  when  examined 
under  a  low  power  of  the  microscope,  are  both  interesting  and  characteristic. 
About  the  end  of  the  first  week  after  sowing,  before  any  change  is  per- 
ceptible with  the  naked  eye,  sinuous  lines  may  be  observed  on  the  surface. 
The  smaller  are  like  the  letter  S,  the  larger  have  been  compared  by  Koch 
to  the  arabesques  of  ornamental  writing.  These  curved  figures  are  seen  to 
be  composed  of  bacilli  arranged  in  columns.  The  bacilli,  although  close 
together,  are  separated  from  one  another  by  clear  spaces.  Cultures  appear 
to  retain  during  many  generations,  without  modification,  the  original 
properties  of  the  bacillus.  Cultures  continued  by  Koch  during  nine  years, 
external  to  the  body  of  any  animal,  had  preserved  unchanged  their  proper- 
ties, except  for  a  slight  diminution  in  virulence. 

We  have  alluded  to  certain  appearances  in  the  bacilli  which  suggested 
the  existence  of  spores.  One  of  the  main  arguments  against  such  being 
due  to  spores  is  that  the  bacilli  in  which  they  occur  are  not  more  resistant 
than  other  bacilli  to  the  influence  of  heat,  desiccation,  etc.  The  fact  that 
caseous  matter  in  which  bacilli  cannot  be  recognised,  is  sometimes 
extremely  virulent,  suggests  that  spores  are  very  probably  present  in  it. 
It  is  possible  that  bacilli  may  be  actually  present  in  such  material,  and 
have  been  overlooked  on  account  of  their  fewness.  This,  however,  would 
not  explain  virulence.     In  old  cultures  but  few  bacilli  may  be  found, 


TUBERCUL  OSIS.  357 

together  with  round1  granules  which  strongly  fix  the  colouring  matter. 
Sown  on  a  suitable  medium,  such  old  cultures  give  rise  to  typical  young 
cultures.  It  seems  likely  that  the  growth  has  resulted  from  the  granules 
just  mentioned.  Similar  granules  are  to  be  found  in  the  virulent  caseous 
material  in  which  bacilli  are  absent,  or  at  any  rate  cannot  be  detected. 

Identity  in  different  situations.  —  The  identity  of  the  bacillus  in 
human  and  mammalian  tubercle  may  now  be  considered  to  be  established 
without  a  doubt.  Besides  producing  exactly  similar  lesions  when  inoculated, 
they  have  the  same  form,  appearance,  and  modes  of  staining  and  cultivation. 
It  is  otherwise,  however,  with  the  bacillus  of  avian  tubercle,  regarding  the 
relation  of- which  with  the  mammalian  tubercle  bacillus,  a  fierce  controversy 
has  been  going  on.  The  two  bacilli  are  indistinguishable  in  form  and  colour- 
ing reaction.  But  although  morphologically  so  much  alike,  there  are  such 
striking  biological  differences  between  the  two,  and  such  different  effects 
from  inoculation  experiments,  that  there  seems  to  be  little  doubt  that  they 
are  entirely  distinct.  Koch  says :  "  I  do  not  hesitate  to  maintain  that  the 
bacilli  of  fowl  tuberculosis  are  a  species  by  themselves,  but  closely  related 
to  the  (mammalian)  tubercle  bacilli." 

While  the  mammalian  bacillus  cannot  be  cultivated  at  a  temperature  over 
42°  C,  the  avian  nourishes  at  43°  C,  and  can  be  successfully  cultivated  at 
45°  C,  and  even  above.  There  is  a  striking  difference  in  the  appearance 
and  consistence  of  young  cultures  in  solid  media :  the  mammalian  are 
greyish,  coherent,  dry,  hard,  and  difficult  to  spread  out  evenly  on  a  cover- 
glass;  the  avian  are  whitish,  soft,  moist,  and  easily  spread  out.  Avian 
cultures  preserve  their  vitality  much  longer  than  mammalian  cultures. 
But  the  most  striking  differences  exist  in  regard  to  their  inoculability, 
which  will  be  referred  to  later  on. 

Influence  of  surroundings  on  bacilli. — There  is  good  reason  to  believe 
that  the  principal  mode  in  which  tuberculosis  is  spread  is  by  the  dissemina- 
tion of  dried  sputum  from  the  subjects  of  pulmonary  tuberculosis.  It  is 
therefore  necessary  to  know  what  is  the  effect  of  various  circumstances  and 
agencies  on  the  vegetability  and  virulence  of  tubercle  bacilli.  A  culture, 
5  to  6  months  old,  can  only  exceptionally  be  recultivated ;  at  the  end  of  8 
to  12  months,  recultivation  is  impossible.  The  virulence  diminishes  with 
the  age  of  the  culture,  and  cultures  8  to  12  months  old  produce  the  same 
effects  as  dead  bacilli  when  inoculated. 

Dried  sputum  containing  tubercle  bacilli  has  been  shown  to  remain 
virulent  for  several  months,  but  after  a  time  the  virulence  gradually 
diminishes  until  it  is  finally  lost.  Bacilli  retain  their  vitality  for  from  two 
to  four  months  when  kept  in  sterilised  water.  Putrefaction,  whether  in 
air,  in  light  or  darkness,  in  water  or  underground,  has  no  effect  for  a  long  / 
time  on  the  virulence  of  the  bacillus.  The  carcases  of  tuberculous  animals 
in  an  advanced  condition  of  putrefaction  have  been  found  still  to  con- 
tain matter  capable  of  producing  tuberculosis  by  inoculation. 

The  bacilli  offer  great  resistance  to  the  action  of  gastric  juice.  They 
have  been  found  still  virulent  after  six  hours'  digestion,  at  a  temperature  of 
38°  C,  in  gastric  juice,  obtained  through  a  fistula  from  the  stomach  of  a 
healthy  dog.  Bacilli  show  great  resistance  to  cold.  Successive  freezing 
and  thawing  for  several  weeks  have  been  found  to  have  no  effect  on  the 
virulence  of  tuberculous  material.  A  great  many  experiments  have  been 
carried  out  to  determine  the  effect  of  heat  on  the  vegetability  and  virulence 
of  the  bacillus.  Dried  bacilli  are  more  resistant  than  moist  to  exposure  to 
heat,  and  dry  heat  is  less  destructive  than  moist  heat.    It  may  be  taken 


358  GENERAL  DISEASES. 

as  an  established  fact  that  an  exposure  for  five  minutes  to  the  action  of 
boiling  water  is  sufficient  to  kill  bacilli.  Yersin  found  that  exposure  to 
moist  heat  at  70°  C,  or  over,  for  ten  minutes  had  this  effect.  Forster 
found  that,  while  moist  heat  at  70°  killed  in  five  to  ten  minutes,  at  60° 
forty-five  to  sixty  minutes  were  required,  and  at  50°  twelve  hours  had  no 
effect. 

Under  the  influence  of  heat,  the  vegetability  disappears  before  the 
virulence.  Woodhead  states :  "  The  most  deadly  tuberculous  material  can 
be  rendered  absolutely  innocuous,  so  far  as  any  spreading  infective  disease 
is  concerned,  by  the  action  of  a  temperature  at  which  water  boils.  We 
have  evidence  that  a  lower  temperature  than  this  is  sufficient  to  bring 
about  the  same  results  when  allowed  to  act  for  a  longer  time ;  but  for  the 
present  it  is  sufficient  to  state  that  boiling  for  an  instant  even  renders  the 
tubercle  bacillus  absolutely  innocuous."  Woodhead  found  that  artificial 
tuberculous  milk,  heated  at  80°  C.  for  ten  minutes,  was  not  always  in- 
nocuous. One  pig  fed  with  such  material  became  tuberculous.  There 
are  considerable  discrepancies  among  the  results  obtained  by  different 
observers,  and  it  is  obvious  that  the  effect  of  "  boiling  for  an  instant " 
may  vary  considerably,  according  as  the  processes  of  heating  and  subse- 
quent cooling  are  slow  or  quick.  There  is  no  doubt,  however,  that  for 
practical  purposes  Woodhead's  contention  is  absolutely  true. 

Pasteurisation  or  sterilisation  of  milk  cannot  altogether  be  depended 
on  to  kill  bacilli  which  may  be  contained  in  it.  The  temperature  to  which 
the  milk  is  brought  never  reaches  95°  C.  Sunlight  has  a  powerfully 
destructive  action  on  bacilli.  Exposure  to  the  direct  solar  rays  kills  them 
in  a  few  minutes  or  a  few  hours,  according  to  the  thickness  of  the  stratum. 
Straus  found  that  very  abundant  cultures  were  killed  in  two  hours  after 
exposure  to  the  summer  sun.  Diffused  daylight  has  also  a  powerful  though 
slower  effect.     Exposure  to  it  kills  the  bacilli  in  from  five  to  seven  days. 

The  influence  of  antiseptic  agents  on  the  bacillus  has  received  much 
study.  Koch  has  experimented  with  a  number  of  these  by  adding  them 
in  small  amounts  to  culture  media.  He  found  that  the  following,  among 
others,  hindered  the  growth  of  the  bacillus  when  present  even  in  very  small 
doses,  namely,  a  number  of  ethereal  oils — /3-naphthylamin,  paratoluidin, 
xylidin ;  certain  aniline  dyes — fuchsine,  gentian- violet,  methylene -blue,  etc  \ 
and  among  metals  the  vapour  of  mercury  and  salts  of  silver  and  gold.  Com- 
pounds of  cyanogen  and  gold  were  specially  active ;  in  a  proportion  of  one 
part  to  one  or  two  million  parts  of  the  culture  medium  they  arrested  the 
growth  of  the  bacillus.  All  these  substances  remained  without  effect  when 
tried  on  tuberculous  animals.  Yersin  found  carbolic  acid,  when  applied 
directly  to  the  bacilli,  most  deadly  to  them.  Thus,  1  in  20  solution  killed 
them  in  thirty  seconds,  and  1  in  100  in  one  minute.  On  the  other  hand,, 
saturated  solutions  of  creosote  and  naphthol  had  no  effect  in  one  hour. 
Schill  and  Fischer  found  that  exposure  of  tuberculous  sputum  to  the  in- 
fluence of  various  antiseptics  for  twenty  hours  had  no  effect  in  destroying 
its  virulence.  An  exposure  to  a  3  per  cent,  solution  of  carbolic  acid  for 
twenty  hours,  or  to  absolute  alcohol  for  ten  hours,  was  found  to  be  effective. 
The  influence  of  sulphurous  acid  gas  has  been  investigated  by  Vallin, 
who  showed  that  bacilli  exposed  for  fourteen  hours  to  the  gas  produced 
by  the  combustion  of  30  grms.  of  sulphur  per  cubic  metre,  were  killed, 
while  exposure  for  twenty-four  hours  to  the  gas  produced  by  combustion 
of  20  grms.  per  cubic  metre,  failed  to  kill.  Iodoform  has  been  found  by 
Stche'goleff  to  exercise  in  vitro  an  antagonistic  action  on  the  bacillus,  but 


TUBERCULOSIS. 


359 


experimental  injections  in  animals  of  iodoform  along  with  bacilli  have  had 
no  deterrent  effect. 

Chemical  constitution  of  bacilli. — By  treating  with  a  mixture  of 
ether  and  alcohol,  Hammerschlag  found  that  bacilli,  previously  well  washed 
and  dried,  lose  27  per  cent,  of  their  weight — a  loss  much  greater  than  is 
experienced  by  any  other  microbe  similarly  dealt  with.  The  extract  so 
obtained  is  formed  of  fat  and  lecithin,  and  a  toxic  substance  which,  on 
injection,  throws  guinea-pigs  and  rabbits  into  convulsions  and  kills  them. 
By  treating  the  residue,  insoluble  in  ether  and  alcohol,  with  a  1  per  cent, 
solution  of  potash,  there  can  be  extracted  an  albuminoid  substance.  The 
substance  which  remains  is  probably  cellulose.  According  to  Koch,  the 
bacilli  contain  two  non-saturated  fatty  acids,  one  of  which  is  soluble  in 
dilute  alcohol,  and  is  easily  saponified  by  the  addition  of  soda,  while  the 
other  only  dissolves  in  boiling  absolute  alcohol  or  ether,  and  saponifies 
with  great  difficulty.  These  two  acids  are  stained  in  the  same  way  as  the 
bacillus,  form  a  continuous  layer  in  its  interior,  and  are  the  cause  of  its 
resistance  to  absorption  in  the  animal  body. 

From  pure  cultures  in  a  medium  containing  glycerin,  Koch  obtained  a 
highly  toxic  extract  which  he  called  tuberculin.  This  substance  was 
originally  introduced  as  a  remedy  for  tuberculosis,  and  in  that  aspect  will 
be  considered  under  the  head  of  treatment.  Koch  was  led  to  the  discovery 
of  tuberculin  by  observing  the  effects  of  the  subcutaneous  injection  of  dead 
bacilli  on  guinea-pigs,  both  healthy  and  tuberculous.  He  concluded  that 
the  tissues  dissolved  out  something  from  the  bacilli  which  had  a  powerful 
toxic  action,  and  this  principle  he  endeavoured  to  extract  artificially. 

The  dead  bacillus  is  not  simply  an  inoffensive  foreign  body;  it  is  a 
toxic  body.  Prudden  and  Hodenpyl  have  shown  that  dead  bacilli,  separated 
from  such  of  their  metabolic  products  as  are  set  free  in  the  culture  media, 
or  are  extracted  by  prolonged  boiling  in  water,  or  50  per  cent,  glycerin,  are 
capable  of  inducing  marked  effects  on  the  body  cells  of  the  rabbit.  Such 
dead  bacilli  are  distinctly  pyogenic,  causing,  when  injected  subcutane- 
ously,  localised  suppuration.  They  are  capable  of  stimulating  the  tissues 
about  the  suppurative  foci,  to  the  development  of  a  new  tissue  closely 
resembling  the  diffuse  tubercle  tissue  induced  by  the  living  microbe. 
There  is,  in  the  nodular  structures  thus  produced,  no  tendency  to  caseation, 
and  no  evidence  of  proliferation  of  the  bacilli,  but  rather  a  diminution  of 
their  number.  These  observers  think  it  possible  that  a  certain  number  of 
the  miliary  tubercles  found  in  the  body,  after  a  generalisation  of  the  tuber- 
culous process  from  an  old  tuberculous  focus,  may  actually  be  innocuous 
growths,  or  at  least  harmful  only  as  foreign  bodies  in  the  tissues  where  they 
develop,  and  that  the  dense  masses  of  fibrous  tissue  present  in  the  lungs 
in  cases  of  healed  tuberculosis  may  be  actually  innocuous,  and  no  longer 
capable  of  lighting  up  a  fresh  infection,  although  harbouring  stainable 
bacilli.  Tubercles  may  be  the  result  of  a  conservative  process,  rendered 
futile  by  a  destructive  tendency  to  caseous  degeneration,  developed  under 
the  influence  of  a  metabolic  product  of  the  living  and  growing  germs 
which  the  tuberculous  foci  still  harbour. 

Straus  and  Gamaleia  have  worked  at  the  same  subject.  Their  conclu- 
sions are  of  great  importance.  They  found  that  dead  bacilli  introduced 
into  the  body  of  an  animal  retained  their  aspect  and  colour  reaction  for 
months.  The  rule  for  other  dead  pathogenic  micro-organisms,  similarly 
introduced  into  the  body  of  an  animal,  is  that  they  rapidly  disappear,  and 
leave  no  trace  behind.     Dead  bacilli  introduced  into  the  peritoneum,  or 


360  GENERAL  DISEASES. 

directly  into  the  circulation,  moreover  produce  lesions  closely  resembling 
those  due  to  living  bacilli.  Even  caseation,  according  to  these  observers, 
is  not  unusual.  In  the  absence  of  anatomical  lesions,  dead  bacilli  are  able 
to  produce  profound  effects  on  the  system,  and  bring  about  progressive 
emaciation,  cachexia,  and  death. 

The  distribution  of  bacilli.  —  Bacilli  in  the  tody.  —  In  the  case  of 
miliary  tubercle,  bacilli  are  in  greatest  abundance  when  the  granulations 
are  comparatively  small  and  recent,  and  gradually  diminish  in  number  as 
caseation  advances,  when  they  are  to  be  seen  only  at  the  periphery.  The 
existence  of  bacilli  in  the  blood  has  been  demonstrated  in  a  few  cases  of 
acute  miliary  tuberculosis. 

In  the  case  of  chronic  tuberculosis,  the  bacilli  are  relatively  few  in 
grey  slowly  growing  tubercle,  but  they  are  particularly  abundant  in  recent 
caseating  and  softening  centres,  and  in  the  interior  of  cavities  whose  walls 
are  rapidly  breaking  down.  They  are  less  numerous  in  older  cavities  with 
thick  walls,  and  still  fewer  in  parts  affected  with  cicatricial  induration. 

Bacilli  in  the  secretions  and  excretions. — Caseating  and  softening 
cavities  in  the  lungs,  it  has  just  been  pointed  out,  contain  abundant 
tubercle  bacilli,  which,  accordingly,  are  readily  found  in  the  sputum  which 
is  expectorated  in  cases  where  such  cavities  exist.  The  number  of  bacilli 
present  in  the  sputum  will  vary  according  to  the  condition  of  the  lungs, 
but  in  an  active  and  progressive  case  it  may  be  beyond  calculation.  In 
renal  or  vesical  tuberculosis,  bacilli  may  be  found  in  the  urine ;  in  uterine 
tuberculosis,  in  the  vaginal  discharges ;  and  in  tuberculous  ulceration  of 
the  intestines,  in  the  fsecal  evacuations.  Neither  the  sweat  nor  the  breath 
contains  bacilli.  In  the  case  of  the  sweat,  experimental  inoculations  have 
proved  quite  innocuous.  Eansome  has  stated  that  he  found  bacilli  in 
the  condensed  breath  of  a  phthisical  patient ;  and  Giboux,  that  he  gave 
tuberculosis  to  two  rabbits,  by  causing  them  to  inhale  the  breath  of 
persons  affected  with  phthisis.  These  isolated  observations  have  not  been 
corroborated  by  other  investigators.  The  results  of  many  most  carefully 
carried  out  experiments  have  been  quite  negative,  and  the  evidence  against 
the  infectivity  of  the  breath  is  overwhelming. 

The  milk  of  tuberculous  women,  cows,  or  other  animals  has  not  been 
conclusively  proved  to  contain  bacilli  or  to  be  infective,  unless  the  breast 
or  udder  is  affected  with  tubercle.  A  large  number  of  experiments  by 
inoculation  and  feeding  with  the  milk  of  tuberculous  cows,  free  from  udder 
disease,  were  made  by  Sidney  Martin  for  the  Eoyal  Commission  of  1890, 
with  negative  results.  Eecently,  however,  Adami  in  Canada,  and  Eabino- 
witsch  in  Berlin,  have  reported  finding  what  they  took  to  be  tubercle  bacilli 
in  the  milk  of  such  cows,  but  they  have  not  succeeded  in  proving  by 
inoculation  that  the  bacilli  were  genuine  tubercle  bacilli. 

Bacilli  outside  the  body. — The  chief  outlet  for  the  bacilli  from  the 
human  body  is  by  means  of  the  expectoration.  A  phthisical  patient  with 
active  disease  expectorates  in  the  twenty-four  hours  thousands  of  millions 
of  bacilli.  Among  the  lower  classes  in  England,  as  well  as  abroad,  expector- 
ation is  freely  deposited  on  the  pavement  and  on  the  floors  of  rooms  or 
public  conveyances,  or  is  spat  into  handkerchiefs,  where  it  is  allowed  to  dry. 
The  dried  expectoration  thus  becomes  scattered  about  in  the  rooms  where 
phthisical  patients  live,  and  these,  together  with  public  conveyances  and 
places  of  entertainment  or  public  worship,  can  hardly  escape  becoming 
foci  of  infection.  We  have  seen  how  long  dried  bacilli  will  retain 
their  virulence,  and  for  the  dried  sputa  the  same  is  true. 


TUBER  CUL  OSIS.  3  6 1 

A  most  exhaustive  research  on  the  distribution  of  the  bacillus  outside 
the  body  was  made  by  Cornet.  He  experimented  with  dust  collected  in 
various  quarters  of  Berlin.  Intraperitoneal  injections  were  made  with 
this  dust  on  392  guinea-pigs.  In  128  cases  the  dust  communicated 
tuberculosis.  He  found  it  most  frequently  virulent  in  hospital  wards 
containing  phthisical  patients,  then  in  private  rooms  occupied  by  the  same, 
and  next  in  the  galleries  of  lunatic  asylums.  The  dust  from  the  street, 
from  surgical  wards,  or  from  private  houses  not  occupied  by  consumptives, 
gave  negative  results. 

More  recently  Straus  succeeded  in  proving  the  existence  of  tubercle 
bacilli  in  the  interior  of  the  nasal  cavity  of  healthy  individuals  frequenting 
places  inhabited  by  consumptives.  He  found  that  out  of  twenty-nine 
individuals,  free  from  the  slightest  suspicion  of  tuberculosis,  nine  harboured 
the  tubercle  bacillus  in  their  nasal  cavities.  Of  these  nine,  six  were 
hospital  porters  whose  duties  were  cleaning  and  dusting,  two  were 
hospital  students,  and  one  was  a  patient  who  had  been  some  months  in 
the  hospital.  The  tubercle  bacillus  has,  moreover,  been  found  in  the  bodies 
and  excrement  of  flies  in  apartments  occupied  by  consumptives.  It  is 
obviously  of  vast  importance  that  the  expectoration  of  tuberculous 
patients  should  be  so  dealt  with  that  its  virulence  may  be  destroyed.  On 
this  subject  we  shall  say  a  few  words  later. 

The  modes  of  infection. — These  are  inoculation,  inhalation,  and 
ingestion  into  the  alimentary  tract. 

Inoculation. — Villemin  in  1865  first  clearly  demonstrated  that 
tuberculosis  was  a  disease  inoculable  in  the  lower  animals.  He  took 
material  from  tuberculous  lesions,  and  inserted  it  under  the  skin  of  various 
animals,  and  found  that  the  disease  was  thereby  reproduced  in  these 
animals.  His  conclusions  were  at  the  time  fiercely  opposed,  but  have 
now  long  been  universally  accepted  and  confirmed.  When  the  bacillus 
was  discovered,  its  pure  cultures  were  immediately  found  to  be  capable 
of  producing  the  disease  by  inoculation.  One  of  the  most  certain  modes  of 
producing  tuberculosis  experimentally  is  by  intraperitoneal  inoculation.  The 
guinea-pig  is  the  most  sensitive  animal  to  such  inoculations,  which  accord- 
ingly furnish  a  most  conclusive  method  of  testing  whether  suspected  material 
is  tuberculous  or  not.  Inoculation,  however,  is  a  very  unusual  mode  of  in- 
fection in  the  human  subject.  The  disease  produced  by  inoculation  in  man 
is,  moreover,  as  a  rule  a  local  one.  Instances  of  local  tubercle  on  the  hands 
have  been  met  with  in  the  case  of  washerwomen,  and  post-mortem  room 
porters  and  demonstrators ;  and  tuberculosis  has  occasionally  been  com- 
municated like  syphilis  by  circumcision,  in  some  of  which  cases  suction  of 
the  wound  by  a  phthisical  operator  has  been  found  to  be  the  cause.  The 
communication  of  tubercle  by  vaccination  may  be  said  to  be  absolutely 
without  proof.  The  cases  where  such  has  been  alleged  do  not  bear 
investigation.  All  experiments  hitherto  scientifically  made  have  proved 
negative. 

Inhalation. — Villemin  also  was  the  first  to  show  that  tuberculosis 
could  be  communicated  by  inhalation  of  dried  tuberculous  products,  and 
to  recognise  the  clanger  and  infectivity  of  dried  sputum  from  a  tuber- 
culous patient.  Since  his  time  numerous  experiments  have  proved  that 
the  inhalation  of  air  containing  dried  tuberculous  expectoration  will 
readily  induce  tuberculosis  in  even  the  most  refractory  animals.  The  fact 
that  the  lungs  and  the  bronchial  glands  are  the  earliest  as  a  rule  to  suffer 
in  tuberculosis,  and  that  they  are  by  far  the  most  commonly  and  most 


362  GENERAL  DISEASES. 

widely  affected,  argues  strongly  in  favour  of  the  view  that  it  is  by  means 
of  inhalation  that  man  most  commonly  becomes  infected  by  tubercle. 
Experimental  tuberculisation,  however,  has  demonstrated  that,  in 
whatever  way  the  bacilli  may  be  introduced  into  the  body,  whether  by 
hypodermic  or  intraperitoneal  injection,  or  by  the  mouth,  the  lungs  may 
suffer  out  of  proportion  to  the  rest  of  the  body.  A  process  of  exclusion  will 
show  that  in  the  vast  majority  of  cases  infection  must  come  by  the  air. 

We  have  seen  how  universal  the  tubercle  bacillus  is  in  the  dust  of 
rooms  which  have  been  occupied  by  phthisical  patients.  We  know  that 
the  opportunity  for  infection  by  inhalation  exists  wherever  phthisical 
patients  have  been  recently,  who  have  been  careless  about  the  disposal  of 
their  expectoration.  Both  theory  and  experiment  combine  to  show  that 
inhalation  is  by  far  the  most  common  mode  of  infection. 

Ingestion. — Whilst  tuberculosis  by  inhalation  is  undoubtedly  the 
most  common  mode  of  infection,  it  has  been  abundantly  shown  that  tuber- 
culosis may  be  communicated  by  food.  Animals  fed  on  tuberculous  matter 
seldom  fail  to  become  tuberculous  themselves.  Different  kinds  of  animals 
differ  in  the  facility  with  which  they  are  rendered  tuberculous  in  this 
way.  The  pig  is  one  of  the  animals  most  susceptible.  The  ruminants  are 
more  readily  affected  than  the  carnivora.  Eabbits  and  guinea-pigs  show 
little  resistance.     Young  animals  are  less  refractory  than  old. 

The  nature  and  situations  of  the  lesions  produced  by  ingestion  are  of 
great  importance  in  connection  with  human  tuberculosis.  In  the  case  of 
the  pig  the  infection  appears  to  occur  at  the  fauces  and  tonsils,  for  the 
malady  begins  in  that  animal  with  swelling  of  the  glands  of  the  neck, 
throat,  and  head,  and  ulcerations  of  the  pharynx  and  soft  palate.  As  a 
rule,  however,  the  first  and  most  evident  lesions  are  met  with  in  the 
intestines,  in  Peyer's  patches,  and  the  solitary  follicles.  Next  to  the 
intestines,  the  mesenteric  glands  are  most  commonly  affected,  then  the 
other  lymphatic  glands,  etc.  It  must  be  pointed  out  that  sometimes  the 
intestines  escape,  while  the  mesenteric  glands  show  infection.  In  man 
the  intestines  very  frequently  become  secondarily  affected,  from  the 
patient  swallowing  the  tuberculous  sputum.  In  children,  and  probably 
also  in  adults,  primary  intestinal  or  mesenteric  tuberculosis  occurs 
as  the  result  of  ingestion  of  tuberculous  food;  but,  as  has  been  said, 
this  mode  of  infection  is  probably  not  nearly  so  common  as  that  by  the 
respiratory  tract. 

We  have  already  referred  to  the  prevalence  of  tuberculous  disease 
among  the  lower  animals,  on  which  subject  more  is  said  below.  The 
disease  is  particularly  prevalent  among  cattle,  and  a  matter  of  vast 
importance  to  the  community  is  the  possibility  of  infection  through  milk 
and  meat.  The  experiments  of  many  observers,  among  them  those  of 
Sidney  Martin,  show,  as  previously  stated,  that  milk  is  usually  not  in- 
fective unless  the  udder  of  the  cow  is  itself  tuberculous.  Where  the 
udder  is  tuberculous,  the  milk,  according  to  Martin,  "possesses  a 
virulence  which  can  only  be  described  as  extraordinary.  All  the  animals 
inoculated  showed  tuberculosis  in  its  most  rapid  forms." 

We  have  seen  that  the  virulence  of  tubercle  bacilli  can  be  entirely 
destroyed  by  boiling.  The  public  have  therefore  a  perfect  safeguard,  if 
they  choose  to  use  it.  As,  however,  a  large  quantity  of  milk  is  consumed 
uncooked,  the  greatest  vigilance  should  be  exercised,  by  systematic  inspec- 
tion of  dairy  cows,  to  prevent  the  delivery  to  the  public  of  contaminated 
milk.     There  is  no  doubt  that  the  danger  is  a  real  one,  but  the  extent  to 


TUBERCULOSIS.  363 

which  infants  are  infected  by  milk  has  been  exaggerated.  The  distribution 
of  the  lesions  in  them  more  frequently  points,  as  it  does  in  adults,  to  in- 
fection by  the  respiratory  tract  than  by  the  alimentary.  Tuberculosis  of 
the  bronchial  glands  is  more  common  than  tuberculosis  of  the  mesenteric, 
and  when  both  exist  the  former  is  usually  the  further  advanced. 

It  has  been  shown  that  butter,  cream,  and  cheese  manufactured  from 
tuberculous  milk  are  equally  infective  with  the  milk  itself.  There  is, 
however,  much  less  risk  of  infection  from  the  ingestion  of  these  substances 
than  there  is  in  the  case  of  milk,  because  the  amount  consumed  at  any  one 
time  is  so  much  smaller.  It  is  a  demonstrated  fact  that  the  presence  of  a 
certain  minimum  number  of  bacilli  is  required  in  order  to  infect  by  means 
of  food.    The  ingestion  of  a  few  bacilli  is  little  likely  to  produce  tuberculosis. 

In  the  case  of  meat,  the  principal  danger  lies  in  contamination  of  the 
surface  with  tuberculous  matter  from  the  internal  organs.  Tubercle  in 
the  interior  of  the  muscles  is  an  extreme  rarity.  As  in  cooking,  the 
exteriors  of  joints,  steaks,  etc.,  are  exposed  to  sufficiently  high  temperatures 
to  kill  any  bacilli  in  matter  with  which  the  surface  may  have  been 
smeared,  ordinarily  such  contamination  will  prove  quite  harmless.  A  real 
danger,  however,  exists  when  joints  are  prepared  by  rolling,  so  that  the 
possibly  contaminated  exterior  comes  to  occupy  a  central  position.  In 
such  cases  surface  bacilli  might  never  be  exposed  to  a  high  enough 
temperature  to  destroy  their  virulence.  As  in  the  case  of  tuberculous 
sputum,  so  in  the  case  of  the  tuberculous  organs  of  an  animal,  precautions 
should  be  taken  rapidly  to  destroy  the  infective  substance,  as  well  as  to 
avoid  contamination  of  the  healthy  parts. 

Geographical  and  racial  distribution. — As  regards  the  geo- 
graphical distribution  of  the.  disease,  it  may  be  said  that  wherever  men  are 
gathered  together,  there  tuberculosis  will  be  found.  Where  they  lead  a 
healthy  out-of-door  life,  and  are  well  housed  and  well  fed,  there  tuberculosis 
will  be  rare  or  unknown ;  where  the  opposite  conditions  prevail,  it  will  be 
common.  In  all  the  populous  parts  of  Europe,  Asia,  Africa,  America, 
and  Australia,  it  flourishes,  in  spite  of  enormous  differences  of  climate. 
It  is  useless  to  particularise  its  distribution  in  individual  countries.  The 
warm  and  moist  climates  are  more  favourable  for  the  spread  of  tuber- 
culosis than  the  cold  and  dry.  The  best  climate  in  the  world  will  have 
little  counteracting  effect  where  sanitation  is  neglected,  human  beings  are 
crowded  together,  and  the  disease  has  once  been  introduced. 

That  race  has  little  to  do  with  the  incidence  of  the  disease,  is  shown  by 
the  susceptibility  of  peoples,  free  from  the  disease  in  their  own  homes,  when 
placed  under  altered  conditions.  Thus  the  native  of  the  Soudan  frequently 
falls  a  victim  to  phthisis  when  removed  to  Cairo.  In  spite  of  magnificent 
climatic  conditions,  the  Eed  Indian  and  the  Maori  both  readily  succumb 
to  the  disease  when  exposed  to  infection.  The  negro  in  America  and  in 
the  colonised  parts  of  Africa  is  very  liable  to  it. 

While  latitude  and  longitude  appear  to  have  little  to  do  with  the 
prevalence  or  rarity  of  the  disease,  it  has  been  maintained  that  altitude 
has  a  very  important  influence.  It  was  reported  that  phthisis  was 
extremely  rare  in  the  cities  on  the  high  plateaus  of  the  Andes,  such  as 
Santa  Fe  de  Bogota,  Quito,  Puebla,  etc.,  and  in  the  central  plateau  in 
Mexico.  The  rarity  of  tuberculosis  in  these  towns  has  no  doubt  been 
considerably  exaggerated.  The  value  of  the  high  altitudes  depends  on  the 
dryness,  purity,  and  stillness  of  the  air,  and  the  large  amount  of  sunshine 
during  the  winter  months.     It  has  been  shown  by  Bowditch  in  the  United 


364  GENERAL  DISEASES. 

States,  and  Sir  George  Buchanan  in  this  country,  that  excess  of  moisture  of 
the  subsoil  goes  along  with  an  increased  prevalence  of  the  pulmonary  form 
of  tuberculosis.  Improved  drainage  of  the  subsoil  is  followed  by  diminu- 
tion of  the  death-rate  from  pulmonary  phthisis.  It  is  probable  that 
dampness  of  the  dwelling,  due  to  a  moist  subsoil,  acts  indirectly  by  setting 
up  catarrhal  conditions  of  the  respiratory  tract. 

Distribution  among  the  lower  animals. — Tuberculosis  is  a  disease 
to  which  not  only  man,  but  many  domestic  animals,  fall  victims,  and  its 
occurrence  in  the  latter  is  of  great  interest  in  connection  with  the  causa- 
tion and  dissemination  of  the  malady.  Wild  animals  are  also  liable  to 
be  affected  by  it  when  kept  in  captivity,  but  it  is  not  certain  that  it 
ever  affects  them  except  under  artificial  conditions.  The  disease  is  capable 
of  being  inoculated  in  probably  every  member  of  the  mammalian  class. 
Under  the  names  of  Pommeliere,  Perlsucht,  and  Pearl  disease,  bovine 
tuberculosis  has  been  known  for  many  years  as  one  of  the  most  common 
and  most  fatal  diseases  of  cattle  in  this  and  other  countries. 

From  the  records  of  the  Copenhagen  slaughter-houses,  we  find  that, 
during  the  four  years  1890-93,  out  of  132,294  oxen  and  cows,  23,305 
showed  evidences  of  tubercle,  giving  a  proportion  of  17*7  per  cent.  In 
1893-94,  18,462  cattle  were  tested  by  means  of  tuberculin  in  Denmark  in 
717  farms;  7428  were  found  to  be  tuberculous,  or  40*2  per  cent.  In 
Holland,  in  the  large  towns,  a  large  and  increasing  proportion  of  cattle 
are  found  to  be  tuberculous.  In  Germany,  tuberculosis  of  cattle  appears 
to  be  equally  common.  From  the  Berlin  slaughter-houses,  the  report  of 
the  year  1892-93  states  that  out  of  142,874  oxen  and  cows,  21,603  showed 
evidences  of  tubercle,  giving  a  proportion  of  15"1  per  cent. 

Similar  statistics  are  not  to  be  had  for  this  country,  a  record  being 
kept  only  of  the  cases  where  the  carcase  has  been  condemned  on  account 
of  tuberculosis.  At  Edinburgh  during  the  four  years  1887-90,  out  of 
112,981  cattle  slaughtered,  414  were  condemned,  on  account  of  tubercu- 
losis, as  unfit  for  human  food.  This  represents  only  a  small  proportion 
of  the  whole  number  affected  with  tuberculosis.  Two  striking  instances  of 
the  prevalence  of  tuberculosis  among  cattle  in  this  country  may  be  men- 
tioned. An  investigation  of  300  milch  cows,  slaughtered  on  account  of  an 
outbreak  of  pleuro -pneumonia,  was  made  in  Edinburgh  in  1890.  Of  these, 
120  were  found  to  be  affected  with  tuberculosis,  or  40  per  cent.,  and  the 
number  in  different  cow-houses  varied  from  12  to  83  per  cent.  The  result 
of  testing  the  Castiecraig  herd  in  1895  showed  that  out  of  forty  cattle, 
which,  with  one  exception,  had  the  appearance  of  being  healthy  and 
vigorous,  thirteen  were  unmistakably  tuberculous,  and  three  doubtfully  so. 
In  infected  breeding  and  dairy  herds  in  New  York,  Nunn  found  a 
maximum  of  98  per  cent,  and  a  minimum  of  5  per  cent,  tuberculous,  while 
in  healthy  country  districts  he  found  hundreds  of  cows  in  adjoining  herds 
without  a  trace  of  tuberculosis  among  them.  Calves  are  much  less  affected 
with  tubercle  than  full-grown  cattle.  Thus  out  of  185,765  calves  in 
Copenhagen,  only  369,  and  out  of  108,248  calves  in  Berlin,  only  125,  showed 
evidence  of  tubercle. 

The  causes  of  the  frequency  of  tuberculosis  among  cattle  are  the  same 
as  those  which  we  find  hold  in  the  case  of  man — overcrowding,  lack  of 
light,  want  of  ventilation,  disregard  of  cleanliness,  insufficient  or  unwhole- 
some food,  overmilking,  breeding  too  young,  and  in-breeding.  Where  such 
conditions  prevail,  the  presence  of  one  case  of  Pommeliere  in  a  cow-house 
will  be  certain  to  be  followed  by  a  more  or  less  general  outbreak.     The 


TUBERCULOSIS.  365 

horse  and  ass  are  only  rarely  affected  with  tuberculosis,  although  both 
can  be  successfully  inoculated  with  the  disease.  Sheep  and  goats  are 
also  but  rarely  affected.  Of  337,014  sheep  at  Copenhagen  in  1890-93, 
only  one,  and  of  355,949  at  Berlin  in  1892-93,  only  fifteen,  were  tuberculous, 
a  very  striking  contrast  to  the  figures  for  cattle.  Isolated  cases  of  tubercu- 
losis in  goats  kept  for  milking  purposes  have  been  from  time  to  time 
recorded.  Both  kinds  of  animals  can  be  readily  rendered  tuberculous  by 
feeding  with  tuberculous  matter,  or  by  intravenous  injection  of  the  same. 
In  the  case  of  swine,  the  prevalence  of  the  disease  holds  an  intermediate 
place  between  that  in  the  case  of  cattle  and  sheep.  Of  8292  swine 
slaughtered  at  Copenhagen  in  the  years  1890-93,  1272  were  tuberculous  ; 
and  of  518,073  at  Berlin,  in  1892-93,  7055  were  affected.  In  1890,  at 
Amsterdam,  out  of  30,406  swine,  323  were  tuberculous.  There  is  a  very 
great  difference,  then,  between  the  statistics  of  different  countries.  Bouley 
suggests  that  the  explanation  is  that  swine  affected  with  tuberculosis  are 
found  not  to  fatten,  and  are  made  away  with  clandestinely.  However  this 
may  be,  it  is  found  that  swine  may  be  very  readily  rendered  tuberculous 
by  feeding  with  tuberculous  material.  Young  pigs  show  a  special  proclivity 
to  the  disease.  In  the  pig  the  lesions  are  chiefly  situated  in  the  digestive 
tract,  which  may  be  affected  throughout  its  whole  length. 

Spontaneous  tuberculosis  of  the  dog,  although  rare,  has  been  fairly 
frequently  recorded.  Eber  of  Dresden  found,  out  of  400  dogs  on  which 
he  made  an  autopsy,  eleven  tuberculous ;  and  Cadiot  at  Alfort  found  forty 
out  of  9000  dogs  tuberculous.  The  dog  appears  to  become  infected  by 
living  with  tuberculous  masters,  and,  as  a  rule,  it  is  infected  through  the 
respiratory  tract.  It  is  easier  experimentally  to  render  dogs  tuberculous 
by  causing  them  to  inhale  infected  air,  than  by  subcutaneous  inoculation. 
Feeding  experiments  have  hitherto  not  been  successful.  On  the  other 
hand,  tuberculosis  can  nearly  always  be  produced  by  means  of  large  intra- 
peritoneal or  intravenous  injections  of  mammalian  tubercle  bacilli.  The 
dog  has  been  found  specially  resistant  to  avian  tubercle,  even  large  intra- 
venous injections  producing  no  appreciable  lesions,  although  a  very  large 
dose  may  induce  a  condition  of  marasmus  terminating  in  death.  A  point 
of  some  interest  is  that  in  canine  tuberculosis  the  liver  is  frequently 
affected  with  tuberculous  nodules,  which  might  easily  be  mistaken  for 
cancerous  growths.  The  cat  is  more  frequently  affected  with  spontaneous 
tubercle  than  is  the  dog,  and  is  more  readily  rendered  tuberculous  experi- 
mentally. According  to  Jensen,  infection  appears  generally  to  take  place 
by  way  of  the  digestive  tract.     Kittens  are  specially  susceptible. 

The  quadrumana  in  confinement  are  extremely  frequently  attacked 
with  tubercle,  which  kills  a  large  number  of  them.  It  is  not  known  that 
they. are  ever  affected  by  the  disease  in  their  natural  condition.  Campbell, 
out  of  thirty-eight  monkeys  examined  post-mortem  at  the  London 
Zoological  Gardens,  found  tuberculous  lesions  in  twenty,  while  Forbes 
found  a  proportion  of  43  per  cent,  in  173  examinations.  The  pulmonary 
form,  as  in  man,  is  much  the  most  frequent.  Nearly  all  classes  of  animals, 
such  as  lions,  tigers,  giraffes,  bears,  panthers,  jaguars,  etc.,  kept  in  confine- 
ment in  zoological  collections,  have  been  found  at  one  time  or  another  to 
be  affected  with  tubercle. 

Although  rabbits  and  guinea-pigs  are  readily  rendered  tuberculous 
experimentally,  there  is  no  satisfactory  evidence  that  they  are  ever 
affected  spontaneously,  except  under  artificial  conditions.  It  has  been 
stated,    however,   that    rabbits  are   frequently  tuberculous,    but  there  is 


366  GENERAL  DISEASES. 

no  evidence  in  support  of  this  assertion ;  all  experimenters  are  agreed 
on  the  absence  of  tuberculosis  among  them,  except  when  artificially 
introduced.  Sidney  Martin  states  that  the  spontaneous  occurrence  of 
tubercle  in  a  rabbit  or  guinea-pig,  in  a  laboratory  for  pathological  research, 
can  only  result  from  a  breach  of  the  strict  hygienic  rules  which  are  a 
sine,  qud  non  of  such  an  establishment.  He  made  597  post-mortem 
examinations  on  guinea-pigs.  In  not  one  of  the  non-experimental  animals, 
203  in  number,  was  a  tuberculous  lesion  discovered,  and  tuberculosis  was 
found  only  in  those  of  the  experimental  animals  which  were  inoculated 
or  fed  with  tuberculous  material. 

Eats  and  mice  are  less  susceptible  to  tuberculosis  than  rabbits  and 
guinea-pigs  ;  and  certain  varieties,  such  as  white  mice,  white  rats,  and  the 
Algerian  rat,  show  a  considerable  degree  of  resistance  to  experimental 
inoculation.  Birds  are  liable  to  be  affected  with  a  form  of  tuberculosis, 
but  there  is  reason  to  believe  that  this  differs  essentially  from  the  ordinary 
disease  which  we  are  considering.  It  has  been  already  pointed  out 
that,  while  the  morphology  of  the  mammalian  and  avian  bacilli  is  practic- 
ally the  same,  there  are  distinct  differences  in  the  vegetability ;  and  the 
appearances  of  the  cultures  are  such  as  to  enable  skilled  observers  at  once 
to  discriminate  between  them. 

Even  more  striking  are  the  differences  in  the  inoculability  of  the  two 
forms  of  tubercle.  Although  a  number  of  cases  have  been  reported  where 
fowls  have  been  said  to  have  become  infected  with  tuberculosis  through  feed- 
ing on  tuberculous  sputum,  such  cases  do  not  bear  investigation,  and  are 
altogether  contrary  to  what  has  been  observed  by  scientific  experiment. 
Straus  and  Wurtz  systematically  fed  eight  fowls  with  tuberculous  sputum 
for  months  without  succeeding  in  infecting  them.  Nocard  equally  failed 
in  feeding  experiments.  Inoculation  experiments  on  birds  have  only  very 
rarely  succeeded  with  mammalian  tubercle,  while  with  avian  success  is  the 
rule.  The  dog,  as  has  been  pointed  out,  has  proved  absolutely  refractory 
to  avian  tubercle,  while  it  is  fairly  readily  inoculable  with  mammalian, 
provided  the  dose  is  a  large  one.  In  the  guinea-pig,  the  inoculation  of 
the  avian  bacillus  scarcely  ever  produces  an  eruption  of  tubercles,  while 
inoculation  with  the  mammalian  does  so  invariably. 

Until  it  has  been  conclusively  shown  that  the  mammalian  tubercle 
bacillus  can  be  transformed  into  the  avian,  and  vice  versd,  the  two  must  be 
regarded  as  distinct,  although  presenting  many  resemblances.  Some  in- 
genious experiments  recently  made  by  Nocard  go  some  way  to  show  that 
this  can  be  done.  He  introduced  collodium  sacs,  filled  with  bouillon 
cultures  of  human  tubercle  bacilli,  into  the  peritoneal  cavities  of  fowls. 
After  some  months  the  fowls  were  killed  and  the  sacs  removed.  After 
several  passages  it  was  found  that  the  bacilli  were  so  altered  as  to  give 
rise  to  what  appeared  to  be  avian  tuberculosis. 

In  birds,  the  digestive  organs  are  the  principal  seats  of  tuberculous 
lesions.  The  liver  is  usually  the  organ  which  is  most  extensively  affected. 
It  becomes  crowded  with  tubercles,  varying  in  size  from  a  millet  seed  to 
a  walnut.  Histologically,  avian  tubercle  closely  resembles  mammalian. 
Giant  cells,  though  sometimes  absent,  are  not  infrequently  present.  Bacilli 
are  often  found  in  extraordinary  abundance. 

It  has  been  estimated  that  about  10  per  cent,  of  farmyard  poultry  are 
affected  with  tuberculosis.  The  common  fowl,  turkeys,  pigeons,  and 
pheasants  are  all  very  liable  to  it.  Ducks  and  geese,  however,  are  seldom 
affected,  and  even  when  much  exposed  to  the  contagion,  remain  immune. 


TUBERCULOSIS.  367 

Parrots  are  frequently  attacked,  and  in  them  there  is  the  peculiarity  that 
the  skin  not  uncommonly  shows  tuberculous  lesions,  especially  about  the 
head.  In  the  case  of  parrots,  it  has  been  maintained  that  the  disease  is 
communicated  by  mouth-feeding,  etc.,  from  the  human  subject ;  and  Straus 
and  others  have  recently  brought  forward  evidence  showing  that  the  parrot 
may  be  affected  by  mammalian  as  well  as  by  avian  tubercle. 

A  form  of  tuberculous  disease  of  fish  has  been  described  by  Dubard. 
The  animals  affected  were  carp,  which  lived  in  a  pond  that  had  been  con- 
taminated with  tuberculous  matter  from  a  phthisical  patient.  Cultures 
from  the  tumours  yielded  bacilli  varying  little  from  the  mammalian 
type.  They  could,  however,  be  grown  at  the  ordinary  temperature  on  all 
the  usual  media,  and  filamentous  and  dichotomous  forms  were  not  un- 
common. The  cultures  were  not  pathogenic  to  warm-blooded  animals. 
The  observations  of  Sibley  in  regard  to  spontaneous  and  experimental 
tuberculosis  in  snakes  require  confirmation.  In  the  case  of  the  frog, 
experimental  inoculation  has  failed,  although  the  presence  of  the  bacilli 
in  the  organs  of  the  animal  has  been  shown  by  the  reproduction  of 
tuberculosis  in  guinea-pigs,  by  inoculation  with  fragments  of  these  organs. 

Experiments  have  been  made  to  show  that  earth-worms  may  form 
vehicles  for  the  tubercle  bacillus.  Tuberculous  matter  was  mixed  with 
the  earth  in  which  the  worms  were  confined.  After  a  few  weeks  both  the 
tissues  of  the  worms  and  the  contents  of  their  intestines  were  found  to  be 
capable  of  producing  tuberculosis  on  inoculation.  These  experiments  also 
require  confirmation. 

Morbid  anatomy. — Miliary  tubercle. — Macroscopic  appearances. — 
The  miliary  tubercle,  when  seen  with  the  naked  eye,  or  by  the  aid  of  a 
magnifying  glass,  appears  as  a  little  round  granule.  It  varies  in  diameter 
from  0*05  mm.  to  2  or  3  mm.  When  recent  it  is  translucent,  of  a  greyish 
white  colour,  but  soon  becomes  opaque  and  yellowish  at  the  centre.  It 
is  often  surrounded  by  a  reddish  vascular  zone.  It  may  be,  however,  im- 
possible to  distinguish  with  the  naked  eye  early  tubercles  from  the  tissues 
in  which  they  are  embedded. 

Histology — When  a  section  of  an  early  tubercle  is  examined  under 
the  microscope,  it  is  seen  to  consist  of  a  group  of  round  cells  arranged 
about  a  centre,  at  which  are  situated  one  or  more  large  multinucleated 
cells — the  so-called  giant  cells.  No  blood  vessels  are  present  in  the  nodule. 
At  a  later  stage  the  centre  of  the  tubercle  will  be  found  to  have  become 
caseous,  to  have  no  definite  structure,  and  to  stain  feebly  or  not  at 
all.  The  various  elements  are  embedded  in  a  ground  substance  of  soft 
protoplasm,  which  sometimes  takes  on  a  fibrillated  or  reticulated 
appearance. 

We  shall  consider  first  the  giant  cell.  The  giant  cell  is  a  body  with  a 
long  diameter  of  from  -05  mm.  to  *2  or  '3  mm.,  of  irregular  shape,  and  con- 
sisting of  granular  protoplasm,  containing  twelve  to  twenty  or  thirty  nuclei, 
which  are  generally  ranged  along  the  margin  or  collected  towards  one 
extremity.  It  has  various  branching  peripheral  processes.  Its  nuclei 
stain  deeply,  and  it  is  thus  well  distinguished  from  the  other  cells.  A 
tubercle  may  contain  several  of  these  bodies.  Surrounding  the  giant  cell 
or  cells  is  a  zone  formed  of  epithelioid  cells.  The  epithelioid  cells  are 
rounded  or  flattened  bodies,  slightly  larger  than  leucocytes,  with  granular 
protoplasm,  containing  one  or  more  oval  vesicular  nuclei,  which  stain 
feebly.  The  epithelioid  cells  may  be  grouped  only  in  close  proximity  to 
the  giant  cell,  or  they  may  reach  quite  to  the  periphery  of  the  tubercle. 


368  GENERAL  DISEASES. 

Finally,  there  is  a  zone  consisting  of  small  round  cells,  with  single 
relatively  large  nuclei  which  stain  readily.  These  have  been  called 
embryonic  or  lymphatic.     They  are  usually  closely  set. 

Retrograde  changes. — A  characteristic  feature  of  the  tubercle  is  the 
absence  or  obliteration  of  vessels.  In  association  with  this  we  find  the 
central  parts  of  the  tubercle  undergo  a  transformation,  consisting  in 
caseous  degeneration.  This  degeneration  results  in  the  fusion  of  the 
cellular  elements  and  their  infiltration  by  fatty  granules.  It  commences 
at  the  centre  of  the  tubercle  in  the  giant  cell,  and  gradually  spreads  to  the 
periphery.  The  tubercle  then  becomes  opaque  and  yellowish,  and  the 
details  of  its  structure  quite  obscure,  and  it  is  no  longer  capable  of  being 
coloured  by  staining  reagents.  Later,  the  caseous  matter  may  soften,  and 
if  there  is  an  outlet  for  this  softened  material,  as  in  the  case  of  the  lung, 
kidney,  or  intestine,  it  may  be  eliminated.  "With  or  without  softening, 
caseous  matter  may  undergo  another  change,  becoming  calcified  from 
deposition  of  lime  salts,  principally  the  phosphate.  Calcification  is  a 
frequent  change  in  old  tubercle  in  cattle  and  swine  as  well  as  in  man.  It 
occurs  also  in  avian  tuberculosis.  It  has  not  been  observed  in  guinea-pigs  or 
rabbits.  Instead  of  undergoing  caseation,  tubercles  are  sometimes  converted 
into  fibrous  tissue.  They  then  form  little  hard  nodules,  formed  of  homo- 
geneous fibrous  tissue,  containing  scanty  small  round  cells,  and  are  generally 
devoid  of  vessels.  This  change  is  less  frequent  than  the  caseous.  The 
caseous  tubercle  is  one  which  has  died  young.  The  fibrous  is  one  which 
has  grown  slowly,  and  has  passed  into  this  condition  without  caseating. 
Sometimes  the  two  processes  are  combined,  the  central  part  caseating  while 
the  peripheral  becomes  fibrous.  The  caseous  material  then  becomes 
encysted,  and  may  later  become  calcareous.  The  fibrous  change  is  fre- 
quently accompanied  by  pigmentation. 

Confluent  tubercle,  the  tuberculous  infiltration  of  Laennec. — In 
association  with  the  bodies  just  described  are  often  seen  larger  grey  or 
yellow  caseous  masses,  either  in  the  lung  or  glands  or  elsewhere.  The 
essential  identity  of  these  masses  with  the  miliary  tubercle  was  main- 
tained by  Laennec,  and  although  this  was  denied  by  Virchow,  and  disputed 
by  many  pathologists,  it  has  now  been  thoroughly  established,  and  both 
have  been  shown  to  be  dependent  on  the  presence  of  the  tubercle  bacillus. 
The  larger  masses  in  most  cases  result  simply  from  the  coalescence  of  a 
number  of  closely-set  miliary  tubercles,  each  of  which  has  undergone 
caseous  degeneration,  and  unites  to  form  a  caseous  whole,  in  which  it  is 
impossible  to  recognise  the  individual  tubercles.  On  a  smaller  scale,  this 
coalescence  takes  place  even  in  the  case  of  the  bodies  which,  from  their 
size,  may  be  called  miliary,  the  larger  of  these  being  always  formed  by 
the  fusion  of  several  smaller. 

Some  maintain  that  the  larger  masses  always  arise  in  the  manner  just 
described,  but  it  is  not  possible  to  give  a  satisfactory  demonstration  of  this ; 
and  it  seems  very  probable  that  without  formation  of  actual  miliary 
tubercles,  with  or  without  giant  cells,  a  diffuse  tuberculous  process,  charac- 
terised by  a  small-celled  growth,  consisting  of  epithelioid  and  small  cells, 
may  arise.  Such  a  small-celled  growth,  at  any  rate,  is  frequently  found  in 
the  lungs,  infiltrating  the  bronchial  sheaths  and  the  alveolar  walls,  and 
accompanied  by  a  similar  growth  in  the  alveoli  and  in  the  lumina  of  the 
bronchi.  That  this  is  really  tuberculous  and  essentially  the  same  as  the 
miliary  tubercle,  although  differing  from  it  in  form,  is  shown  by  its  passing 
through  the  same  transformations  as  the  latter  does,  and  by  its  constant 


TUBERCULOSIS.  369 

association  with  the  tubercle  bacillus.  The  tuberculous  infiltration  may 
caseate,  and  the  necrosed  tissue  may  soften,  separating  and  being  discharged 
at  the  surface  of  the  mucous  membranes,  or  forming  an  abscess  where 
there  is  no  outlet ;  or  it  may  undergo  the  fibroid  transformation ;  or,  as 
in  the  case  of  the  miliary  tubercle,  both  these  processes  may  be  com- 
bined. Tubercle  in  either  of  the  two  forms  just  mentioned  may  be,  and 
frequently  is,  associated  with  simple  inflammatory  processes. 

Relations  of  tuberculous  lesions  to  bacilli  and  other  micro- 
organisms.— We  have  hitherto  said  nothing  as  to  the  exact  relation  of  the 
bacillus  to  the  tubercle.  There  is  nothing  absolutely  diagnostic  of  tubercle 
in  its  anatomy.  Certainty  as  to  the  nature  of  a  suspected  lesion  can  be 
established  only  by  the  discovery  in  it  of  the  tubercle  bacillus.  Bacilli  are 
to  be  found  most  certainly  in  young  and  growing  tubercles,  where  the  latter 
are  beginning  or  rapidly  developing.  One  or  two  bacilli  appear  outside 
the  nucleus  in  the  interior  of  the  epithelioid  cells.  At  a  later  stage  they 
increase  in  number,  occasionally  filling  the  whole  cell.  It  is,  however,  in 
the  giant  cells  that  the  presence  and  distribution  of  the  bacilli  are  most 
characteristic  and  interesting.  The  number  of  bacilli  seems  to  be  in 
inverse  proportion  to  the  number  of  giant  cells.  "Where  these  are  abundant 
the  bacilli  are  few,  where  scanty  the  bacilli  are  numerous. 

In  the  case  of  slowly-growing  tubercles,  the  bacilli  are  in  general  few, 
and  are  met  with  almost  exclusively  in  the  giant  cells,  and  there  in  very 
small  number.  When  the  growth  is  more  rapid,  the  number  of  bacilli 
contained  in  the  giant  cells  becomes  very  large,  and  may  exceed  fifty.  In 
suitably  stained  sections  they  may  be  seen,  under  a  comparatively  low 
power,  forming  tiny  red  or  blue  rings  within  the  circle  formed  by  the 
nuclei..  When  the  bacilli  are  few,  they  generally  occupy  a  position  either 
at  the  centre  or  at  the  pole  opposite  to  the  nuclei.  At  the  commencement 
of  caseation,  especially  when  the  process  is  rapid,  the  bacilli  are  still  visible 
in  large  number.  Later,  they  cease  to  fix  the  colouring  reagent.  Never- 
theless in  caseous  centres  there  exist  modified  forms  of  the  bacilli  which, 
although  impossible  to  stain,  are  virulent  and  capable  of  growth  and  re- 
production. 

It  is  chiefly  to  the  researches  of  Baumgarten  that  we  are  indebted 
for  a  knowledge  of  the  histogenesis  of  tubercle.  He  has  shown  that  the 
presence  of  the  bacilli  in  the  tissues  is  followed  by  karyokinesis  of  the 
fixed  cells,  the  connective  tissue  cells,  the  endothelial  cells,  or  the  epithelial 
cells,  as  the  case  may  be.  The  cells  which  undergo  karyokinesis  may  con- 
tain one  or  more  bacilli,  but  in  most  cases  the  bacilli  are  near  but  not 
included  in  the  cells.  All  the  stages  of  transformation  of  the  fixed  cells 
into  epithelioid  cells  can  be  witnessed.  The  early  tubercles  almost  exclus- 
ively consist  of  such  epithelioid  cells  derived  from  the  fixed  cells.  A  little 
later,  leucocytes  make  their  appearance,  derived  by  diapedesis  from  the 
neighbouring  vessels.  These,  however,  do  not  undergo  such  modifications 
as  division  of  nuclei  and  increase  of  protoplasm,  but  rather  shrivel  up,  and 
later  break  up  into  small  granules.  In  some  cases  the  invasion  of  leuco- 
cytes may  be  so  rapid  and  active  that  the  tubercle  may  assume  the  appear- 
ance of  a  group  of  leucocytes.  When  the  process  is  slower,  the  leucocytes 
may  be  almost  entirely  absent,  and  the  tubercle  then  remains  composed 
almost  entirely  of  epithelioid  cells.  It  is  the  presence  of  the  leucocytes 
which  determines  the  caseous  degeneration.  The  giant  cells  result  from 
the  proliferation  of  the  nuclei  of  the  epithelioid  cells,  of  which  the  proto- 
plasm increases  but  shews  no  tendency  to  division.  Baumgarten  supposes 
vol.  1. — 24 


37Q  GENERAL  DISEASES. 

that  for  the  production  of  giant  cells  a  more  feeble  degree  of  irritation  is 
required,  and  that,  when  the  irritant  is  intense,  cellular  division  becomes 
complete,  with  the  result  that  only  epithelioid  cells  are  met  with  in  the 
tubercle.  Thus,  in  acute  miliary  tubercle,  where  the  bacilli  are  abundant, 
the  giant  cells  are  few ;  in  lupus,  where  they  are  few,  the  giant  cells  are 
numerous. 

The  conclusion  is  that  the  epithelioid  cells  and  the  giant  cells  are 
derived  by  karyokinesis  from  the  fixed  cells  of  the  tissues,  and  while 
migrating  cells  escape  from  the  inflamed  vessels  in  the  neighbourhood  and 
invade  the  tuberculous  nodule,  these  last  are  not  capable  of  further  evolu- 
tion, give  birth  neither  to  epithelioid  nor  giant  cells,  but  rapidly  undergo 
the  ordinary  changes  of  disintegration. 

Metchnikoff's  views,  which  are  not  generally  accepted,  are  that  the 
epithelioid,  as  well  as  the  giant  cells,  are  phagocytes  of  mesodermic  origin ; 
and  that  the  giant  cells,  far  from  being  elements  struck  with  partial 
necrosis,  are,  on  the  contrary,  particularly  living,  and  constitute  the 
essential  defence  of  the  organism  against  the  parasite  of  tuberculosis. 

Other  micro-organisms. — Of  late  years  a  good  deal  of  attention  has 
been  directed  to  other  micro-organisms  which  have  been  found  associated 
with  the  tubercle  bacillus  in  tuberculous  lesions.  It  has  almost  seemed  as 
if  the  unity  which  had  been  restored  by  the  discovery  of  Koch  was  once 
more  to  be  disturbed  and  duality  re-established. 

It  is  principally  in  connection  with  the  lesions  in  chronic  pulmonary 
tuberculosis  that  these  microbes  have  been  found,  but  they  have  also  been 
observed  in  the  acute  form.  The  micrococci  which  are  chiefly  found  are 
the  pneumococcus  and  the  microbes  of  suppuration,  the  Streptococcus  pyo- 
genes and  the  Staphylococcus  aureus.  Sputa  washed  in  sterilised  water,  to 
free  them  from  micro-organisms  derived  from  the  upper  air  passages, 
sometimes  contain  only  tubercle  bacilli,  but  at  other  times  streptococci,  etc., 
are  found.  Some  have  thought  that  the  broncho-pneumonic  lesions  are 
always,  in  the  first  place,  due  to  these  micro-organisms,  and  that  the  tubercle 
bacillus  comes  secondarily  and  causes  the  caseation.  The  hectic  fever  of 
phthisis  has  been  attributed  to  the  invasion  of  the  blood  by  these  microbes 
rather  than  to  the  action  of  the  tubercle  bacillus  and  its  toxines.  Most 
careful  examinations  of  the  blood  by  Straus  have  failed  to  discover  the 
presence  of  any  such  micrococci  during  the  hectic  fever. 

It  seems  probable  that  the  presence  of  micrococci  in  the  affected  parts 
is  an  accidental  and  secondary  phenomenon.  This  is  supported  by  the 
facts,  first,  that  their  presence  is  by  no  means  constant  in  pneumonic  areas ; 
and,  second,  that  intratracheal  injections  of  pure  cultures  of  the  tubercle 
bacillus  will  induce  exactly  similar  lesions  in  which  no  other  microbes  can 
be  found. 

Serum  diagnosis. — A  brief  reference  may  be  made  to  the  recent 
endeavours  of  Arloing  and  Courmont  to  apply  the  method  of  serum 
diagnosis  to  tuberculosis.  For  this  purpose  it  was  first  necessary  to 
produce  a  culture  in  which  the  bacilli  should  be  homogeneously  dis- 
tributed, a  matter  of  great  difficulty.  A  culture  in  glycerin  peptone 
bouillon  was  produced  by  inoculation  with  a  bacillus  much  attenu- 
ated by  long  cultivation  in  the  laboratory.  To  secure  homogeneity, 
the  culture  was  daily  shaken.  Ee-inoculations  were  made  once  a  month, 
the  same  culture  medium  and  the  same  amount  of  mother  culture  being 
used.  The  cultures  thus  obtained  showed  marked  changes ;  the  bacilli 
became  almost  entirely  isolated,  causing  cloudiness  of  the  medium,  and 


TUBERCUL  OSIS.  3  7 1 

their  cultural  properties  proved  to  be  greatly  altered.  Motility  becomes 
a  marked  feature  of  the  liquid  cultures.  When  homogeneous  cultures  thus 
prepared  were  used,  it  was  found  that  normal  blood  serum  produced  no 
agglutination  in  greater  dilution  than  1  in  5,  and  only  occasionally  then. 
In  tuberculous  cases,  agglutination  occurred  in  dilutions  of  from  1  in  5  to 
1  in  20,  the  most  marked  reaction  being  observed  in  cases  where  the 
lesions  were  limited  and  discrete,  and  negative  results  occurring  where  the 
disease  was  widely  spread.  The  great  difficulties  which  have  attended  the 
production  of  homogeneous  cultures  have  prevented  a  trial  of  the  method 
on  a  sufficiently  extensive  scale  to  establish  how  far  dependence  can  be 
placed  on  the  results,  but  it  is  evidently  a  method  which  may  prove  to  be 
of  great  value  in  the  diagnosis  of  early  tuberculosis. 

ACUTE  MILIAEY  TUBEECULOSIS. 

Etiology. — By  far  the  larger  number  of  cases  of  acute  miliary 
tuberculosis  occur  in  early  childhood,  but  in  later  life  it  is  between  the 
ages  of  20  and  30  that  it  is  most  frequently  met  with.  The  disease 
is  usually  secondary,  occurring  for  the  most  part  in  connection  with  chronic 
tuberculosis  of  the  bronchial,  mesenteric,  or  other  glands,  or  of  the  vertebrae 
or  other  bones.  Alcoholic  subjects  appear  to  be  specially  liable  to  acute 
miliary  tuberculosis.  Occasionally  the  disease  occurs  in  an  epidemic  form. 
It  is  evident  from  the  distribution  of  the  lesions  that  the  virus  has  been 
carried  to  the  various  parts  of  the  body  through  the  blood  stream. 

Morbid  anatomy. — In  acute  miliary  tuberculosis  tubercle  appears 
in  nearly  every  organ  in  the  body.  The  lungs  hardly  ever  escape,  although 
the  extent  to  which  they  are  affected  varies  greatly  in  different  cases. 
There  may  be  only  a  sparse  deposit  of  tubercle,  scarcely  visible  to  the 
naked  eye,  or  there  may  be  a  very  general  tuberculous  infiltration. 

We  shall  first  describe  the  pulmonary  form  of  acute  miliary  tubercu- 
losis. In  this,  little  grey  nodules,  just  visible  to  the  naked  eye,  are  thickly 
distributed  throughout  the  lungs.  They  are  often  universally  diffused,  but 
may  be  irregularly  grouped,  possibly  being  more  numerous  in  the  lower 
lobes.  They  are  generally  thickly  distributed  underneath  the  pleura. 
Usually  they  are  discrete,  but  they  may  be  confluent  or  arranged  into 
racemose  clusters.  Often  they  can  be  more  readily  felt  than  seen,  being 
hard  to  the  touch.  They  may  be  surrounded  by  a  zone  of  hyperaemia  and 
pigmentation.  A  few  of  these  nodules  may  be  seen  on  section  to  be  opaque 
in  the  centre,  forming  a  transition  to  another  kind  of  granulation  almost 
as  common.  These  are  somewhat  larger  and  softer,  whitish  in  colour, 
opaque  and  yellowish  at  the  centre  or  yellow  throughout.  They  may 
occur  in  racemose  groups  the  size  of  a  currant  or  raisin.  They  may  soften 
and  form  small  abscesses  and  cavities.  Such  abscesses  may  undermine  and 
perforate  the  pleura  and  cause  pneumothorax,  but  this  is  very  uncommon. 
The  lungs  containing  these  granulations  are  usually  congested  and  redder 
than  normal,  and  are  often  emphysematous.  Here  and  there  are  patches 
of  collapse,  or  larger  or  smaller  areas  of  consolidation,  principally  in  the 
lower  lobes  and  posterior  borders.  Three  forms  of  consolidation  are  met 
with,  first  ordinary  red  hepatisation,  in  which,  however,  tubercles  may 
be  found  under  the  microscope ;  second,  tracts  of  grey,  semi-transparent 
exudation ;  and  third,  infiltration  of  a  uniform  yellow  colour,  at  the  edges 
of  which  fine  yellow  or  white  granulations  may  be  detected. 

When  sections  of  the  lung  are  examined,  after  hardening  and  staining 


372  GENERAL  DISEASES. 

in  the  usual  way,  it  is  found  that  the  grey  miliary  nodules  consist  of  groups 
of  alveoli  filled  with  round  cells.  The  elastic  fibres  of  the  alveolar  walls 
can  be  seen,  but  their  capillaries  can  no  longer  be  made  out.  The  round 
cells  are  granular,  and  contain  nuclei  which  do  not  stain  readily.  They 
are  in  close  apposition  to  one  another.  The  bronchioles,  leading  to  the 
alveoli,  are  also  filled  with  a  similar  exudation,  but  besides  this  there  is  a 
diffuse  thickening  of  their  walls.  This  thickening  has  the  structure  of 
ordinary  tubercle,  such  as  already  described.  Sometimes  it  entirely  sur- 
rounds the  bronchus,  sometimes  is  only  situated  on  one  side  so  as  to  form 
a  crescent.  It  is  generally  found  at  the  terminal  bifurcation  of  the  intra- 
lobular bronchus.  Similar  structures  may  be  seated  on  the  walls  of  the 
minute  branches  of  the  pulmonary  artery.  The  tubercle  of  the  lung  is 
thus  composed  of  tubercle  proper,  together  with  the  exudation  into  the 
interior  of  the  pulmonary  alveoli  and  bronchioles. 

An  important  question  is  whether  the  exudation  in  the  alveoli  differs 
at  all  from  the  ordinary  exudation  of  pneumonia. 

"We  have  seen  that  the  bacilli  first  cause  a  karyokinesis  of  the  fixed 
cells  of  the  tissue,  and  that  later  there  is  an  invasion  of  round  cells  which 
escape  from  the  surrounding  vessels.  The  filling  of  the  alveoli  with  such 
products  cannot  be  considered  as  in  any  way  different  from  that  of 
pneumonia.  It  must  be  remembered,  however,  that  in  pneumonia  the 
walls  of  the  alveoli  undergo  little  change,  the  capillaries  are  uniformly 
distended,  and  the  exudation  may  be  easily  separated.  We  find,  on  the 
other  hand,  in  the  case  of  the  pulmonary  tubercle,  that  the  capillary 
vessels  early  become  obliterated,  this  obliteration  being  a  constant  feature, 
and  the  exudation  cannot  be  removed  without  difficulty.  We  have  already 
referred  to  the  presence  of  other  micro-organisms  besides  the  tubercle 
bacillus  in  these  broncho-pneumonic  areas,  and  stated  that  we  believed 
their  occurrence  to  be  accidental  and  secondary. 

The  serous  membranes  may  be  generally  or  individually  affected. 
There  may  be  effusions  of  serum  in  the  cavities  or  a  deposit  of  sero- 
fibrinous exudation  lining  the  membranes,  while  tubercles  may  be  very 
closely  set  over  the  whole  surface.  For  descriptions  of  these  changes 
and  of  tubercle  of  the  intestines,  reference  must  be  made  to  the  special 
sections  treating  of  the  same. 

When  tuberculous  meningitis  is  present,  it  will  be  observed  that  the 
surface  of  the  brain  is  injected,  and  rather  dry  and  sticky,  while  the  con- 
volutions are  somewhat  flattened.  On  removing  the  brain,  there  is 
probably  a  considerable  escape  of  cerebro-spinal  fluid.  There  is  an 
effusion  of  inflammatory  lymph,  which  as  a  rule  is  limited  to  the  base, 
and  covers  the  chiasma  and  under  surface  of  the  pons  and  medulla.  The 
Sylvian  fissures  are  glued  together,  and  cannot  be  separated  without 
tearing  the  cerebral  tissue.  Tubercles  can  often  be  seen  along  the  various 
branches  from  the  circle  of  Willis,  especially  along  the  middle  and 
posterior  cerebral  arteries,  and  are  best  seen  by  floating  out  these  arteries 
and  their  branches  in  water.  Sometimes  the  microscope  is  required  to 
detect  the  presence  of  tubercles.  Sometimes  the  meningeal  tubercles 
accompanying  meningitis  may  be  larger,  attaining  the  size  of  a  hemp  seed, 
and  in  such  eases  they  may  be  fibrous  and  obsolescent,  showing  that  they 
are  of  considerably  older  standing  than  the  meningitis.  The  lateral 
ventricles  are  frequently  distended  with  fluid,  and  their  floors  are  softened, 
while  tubercles  may  be  found  on  the  velum  interpositum  and  choroid 
plexuses. 


TUBERCULOSIS.  373 

The  lympliatic  glands  are  very  frequently  affected.  One  or  more  of  the 
bronchial  glands  are  enlarged  and  caseous,  and  a  similar  condition  is  often 
found  in  the  mesenteric  glands.  The  liver  almost  always  contains  miliary 
tubercles.  A  few  are  generally  to  be  seen  beneath  the  capsule,  but  often 
they  require  the  microscope  for  their  detection.  The  spleen  likewise  is 
usually  affected,  being  enlarged,  and  containing  tubercles  which  may  be 
grey  or  yellow,  and  of  varying  size.  In  the  kidneys  a  few  tubercles  can 
usually  be  seen  on  the  surface  after  stripping  off  the  capsule.  Tubercle 
has  been  found  in  practically  every  organ,  although  less  frequently  in 
others  than  in  those  mentioned.  Tuberculous  phlebitis  and  endarteritis 
are  not  uncommon,  and  will  be  referred  to  under  the  heading  "  Tuberculosis 
of  the  Vascular  System." 

Symptoms. — The  symptoms  of  acute  miliary  tuberculosis  vary  in 
different  cases,  according  as  the  stress  of  the  disease  falls  on  one  part  of  the 
body  or  another.  Four  forms  may  be  described,  in  which  most  cases  can 
be  included.  These  are  a  latent  form,  an  abdominal  or  typhoid  form,  a 
pulmonary  form,  and  a  cerebral  form.  Certain  symptoms  which  are 
common  to  all  the  varieties  may  first  be  mentioned.  Among  these  are 
pyrexia,  prostration,  rapidity  of  pulse,  and  cyanosis. 

Fever,  the  most  striking  feature  of  which  is  its  irregularity,  is  more  or 
less  constantly  present.  It  may  be  continuous,  with  but  little  difference 
between  the  morning  and  evening  temperatures ;  or  remittent,  resembling 
that  of  enteric  fever ;  or  intermittent.  Continuous  fever,  with  differences 
between  the  morning  and  evening  temperatures  of  less  than  2°  F.,  is  the 
type  which  has  been  most  frequently  met  with  at  the  Brompton  Hospital. 
In  the  remittent  type,  the  afternoon  or  evening  temperature  is,  as  a  rule, 
higher  than  the  morning.  Bemissions  of  3°  F.  are  not  uncommon,  both 
the  morning  and  evening  temperatures  being  pyrexial.  Less  commonly 
the  remissions  may  amount  to  5°  or  6°  F.,  the  lower  temperature  being 
normal  or  subnormal,  the  remittent  type  then  becoming  the  intermittent. 
The  remissions  may  be  attended  by  profuse  perspirations.  In  most  cases 
the  remissions  and  exacerbations  are  very  irregular.  Although  the  remis- 
sions are  usual  in  the  morning  and  the  exacerbations  in  the  afternoon,  an 
inverse  type  is  sometimes  met  with,  where  the  temperature  is  higher  in 
the  morning.  This  inverse  type  is  specially  characteristic  of  acute  miliary 
tuberculosis.  In  some  cases  considerable  rises  mark  fresh  outbreaks  of 
tubercle.  Barely  cases  occur  where  there  is  little  or  no  rise  of  temperature. 
In  the  meningeal  form  of  acute  miliary  tuberculosis,  absence  of  fever  is 
not  very  exceptional,  especially  in  the  case  of  adults. 

Prostration  is  a  frequent  accompaniment  of  all  forms  of  acute  miliary 
tuberculosis,  but  is  most  common  with  the  cerebral  form.  It  is  often  out 
of  proportion  to  the  actual  strength  of  the  patient. 

Bapidity  of  pulse  is  the  rule,  the  acceleration  being  sometimes  very 
great.  In  exceptional  cases  the  pulse  rate  is  little  above  normal.  Some- 
times retardation  occurs  with  the  onset  of  cerebral  symptoms. 

A  certain  degree  of  cyanosis  is  often  to  be  noticed.  It  points  to 
involvement  of  the  lungs,  and  accordingly  is  most  marked  in  the  pulmon- 
ary form  of  the  disease.  The  skin  is  usually  moist  with  perspiration,  and 
an  eruption  of  sudamina  often  appears  on  the  chest.  The  taches  cdrebralcs, 
wheal-like  marks,  readily  produced  by  drawing  the  finger-nail  or  the  point 
of  a  pencil  across  the  skin  of  the  chest  or  abdomen,  although  not  peculiar 
to  this  disease,  may  very  often  be  observed,  especially  in  the  cerebral 
form. 


374  GENERAL  DISEASES. 

Epistaxis  occasionally  occurs  either  at  the  onset  or  at  a  later  period. 
More  rarely  haemoptysis  ushers  in  the  disease,  and  sometimes  purpuric 
haemorrhages  appear  on  the  skin,  and  bleeding  occurs  from  the  gums  and 
into  the  serous  cavities  and  joints.  Emaciation  is  not  common  except  in 
protracted  cases  and  in  the  cerebral  form  of  the  disease.  Among  other 
symptoms  occasionally  present  in  all  forms  of  acute  tuberculosis  are  severe 
muscular  pains. 

Choroidal  tubercles  may  sometimes  be  detected  by  ophthalmoscopic 
examination  in  acute  miliary  tuberculosis.  They  are  generally  most 
abundant  near  the  macula  lutea,  and  are  often  situated  about  the  retinal 
vessels,  which  can  be  seen  coursing  over  them.  Their  appearance  is 
that  of  white  round  patches  with  soft  edges.  Their  diameters  vary  from 
little  more  than  that  of  a  retinal  vein  to  more  than  half  that  of  the 
optic  disc.  They  vary  in  number  from  one  or  two  to  twenty  or  thirty 
in  each  fundus.  During  the  progress  of  the  case  the  growth  and  increase 
in  number  of  the  tubercles  may  be  observed.  Their  presence  is,  as  a 
rule,  unaccompanied  by  other  choroidal  changes. 

We  shall  now  consider  the  various  forms  which  the  disease  may 
assume. 

The  latent  form. — In  this  the  symptoms  do  not  specially  point  to 
the  involvement  of  any  particular  organ  of  the  body.  It  is  seldom  that 
any  case  remains  latent  throughout,  but  the  distinctive  features  may  be 
masked,  and  the  symptoms  be  vague  and  indefinite  until  a  late  period  of 
the  disease. 

In  the  abdominal  or  typhoid  form  the  symptoms  closely  resemble 
those  of  enteric  fever,  for  which  the  malady  is  usually  for  a  time  mis- 
taken. The  illness  sets  in  gradually  with  weakness,  fever,  anorexia,  and 
general  malaise.  The  fever,  as  already  described,  differs  from  that  of 
enteric  fever  by  its  irregularity  and  variations.  There  are,  as  a  rule, 
complete  loss  of  appetite  and  great  thirst.  The  tongue  is  usually  coated, 
and  later  becomes  dry.  Occasionally  there  is  vomiting.  Constipation  is 
the  rule,  less  commonly  there  is  diarrhoea.  Peritonitis  is  frequent,  but 
seldom  gives  rise  to  very  acute  symptoms.  The  patient  probably  com- 
plains of  pain  in  the  abdomen,  and  the  latter  is  tender  to  the  touch. 
The  pain  is  seldom  severe.  The  abdomen  as  a  rule  is  distended,  and  often 
assumes  a  globular  shape,  but  it  may  be  retracted.  Sometimes,  but  not 
commonly,  ascites  is  present.  The  spleen  is  usually  slightly  enlarged, 
but  is  not  so  likely  to  be  felt  on  palpation  as  in  enteric  fever.  The  pul- 
monary symptoms  are  slight,  and  only  such  as  result  from  a  moderate 
degree  of  bronchitis.  Acute  delirium  is  uncommon,  but  torpor  and  mental 
dulness  are  usual.  The  illness  is  generally  of  longer  duration  in  this  form 
of  the  disease  than  in  the  pulmonary  or  cerebral  types,  and  may  last  for 
six  weeks  or  two  months. 

The  pulmonary  form  is  characterised  by  dyspnoea,  hurried  respira- 
tion, cough,  cyanosis,  and  the  symptoms  generally  of  diffuse  bronchitis. 

The  disease  in  this  form  usually  commences  with  the  sudden  onset  of 
acute  symptoms.  The  respiration  is  always  hurried,  and  dyspnoea  is  a 
very  striking  feature.  Sometimes  the  quickening  of  the  breathing  occurs 
without  dyspnoea  being  marked,  but  more  commonly  the  two  go  together. 
When  the  difficulty  of  breathing  amounts  to  orthopncea,  as  is  not  infrequent, 
it  is  very  distressing  to  the  patient.  Ordinarily  the  number  of  respirations 
in  the  minute  is  between  thirty-six  and  fifty,  but  a  rate  of  sixty  or  seventy, 
or  in  children  even  ninety  to  the  minute,  has  been  observed.     Cough  is 


TUBERCULOSIS.  375 

seldom  absent,  although  it  may  be  little  troublesome.  In  about  a 
quarter  of  the  cases  expectoration  is  absent.  When  present,  expectora- 
tion is  usually  mucoid,  but  it  may  be  muco-purulent.  It  is  as  a  rule 
of  moderate  amount ;  rarely  it  is  profuse ;  occasionally  it  is  rusty  or 
blood-stained.  A  high  degree  of  cyanosis  is  frequently  to  be  observed. 
The  lips,  cheeks,  and  finger-nails  are  bluish,  and  the  extremities  readily 
become  cold.  Hsemoptysis,  although  rarer  than  the  other  symptoms, 
is  not  very  uncommon  in  this  pulmonary  form  of  the  disease.  It  is 
more  likely  to  occur  where  there  has  been  pre-existing  phthisis. 
The  physical  signs  are  those  of  bronchitis  and  emphysema.  The 
lungs  generally  are  over-resonant.  The  breath  sounds  may  be  weak,  or 
harsh,  or  uneven.  Ehonchi,  sibilant  and  sonorous,  together  with  medium 
crepitations,  are  generally  audible  over  both  lungs.  Earely  there  are 
patches  of  consolidation  large  enough  to  give  rise  to  the  usual  physical 
signs. 

The  cerebral  or  meningeal  form  of  acute  tuberculosis  presents  the 
most  characteristic  symptoms.  The  illness,  which  is  sometimes  preceded 
by  premonitory  symptoms,  has  been  divided  for  descriptive  purposes  into 
three  stages — A  stage  of  excitement  and  nervous  irritation;  a  stage  of 
depression  ;  and  a  stage  of  coma  and  convulsions. 

In  the  premonitory  period,  the  patient  becomes  irritable,  fretful,  and 
wakeful  at  night.  Symptoms  of  the  pronounced  disease,  such  as  emacia- 
tion, headache,  vomiting,  disorder  of  the  bowels,  slowness  and  irregularity 
of  pulse,  giddiness,  squinting,  or  drowsiness,  may  occasionally  be  met 
with. 

The  first  stage  either  sets  in  quite  suddenly  with  a  fit,  or  more 
gradually  with  fever,  headache,  vomiting,  and  general  irritability.  The 
fever  is  of  one  of  the  types  already  described,  but  the  temperature  is 
seldom  high.  The  pain  in  the  head  is  usually  very  severe  and  paroxysmal, 
so  that  the  patient  screams  out  with  it.  It  is  often  referred  to  the  frontal 
region.  Although  almost  a  constant  symptom  in  children,  it  is  frequently 
absent  in  adults.  Along  with  the  headache  there  may  be  pain  in  the  back 
of  the  neck  and  general  tenderness  of  the  scalp.  Vomiting  occurs  at 
irregular  intervals.  The  bowels  are  constipated.  Irritability  and  fretful- 
ness  become  more  marked,  and  there  is  hyperesthesia  of  all  the  senses. 
The  sleep  is  usually  disturbed,  and  there  may  be  some  delirium  at  night. 
Squinting  or  double  vision,  and  rapidity  alternating  with  slowness  of  pulse, 
are  significant  symptoms  sometimes  met  with  in  this  stage. 

The  onset  of  the  second  stage,  or  the  stage  of  depression,  frequently 
excites  delusive  hopes  of  improvement.  The  fever  somewhat  abates,  or 
the  temperature  may  even  become  normal.  Irritability  is  replaced 
by  apathy.  The  vomiting  ceases.  Sleep  becomes  almost  incessant,  but 
the  patient  can  be  roused  to  take  nourishment  or  to  put  out  the  tongue. 
The  breathing  becomes  irregular,  and  often  assumes  the  Cheyne-Stokes 
character.  The  patient,  during  this  stage  of  drowsiness,  dulness,  and  stupor, 
probably  on  account  of  the  persistence  of  the  headache,  sometimes  utters 
a  sharp,  loud,  plaintive  cry — the  so-called  hydrocephalic  cry.  The  head  is 
usually  retracted.  Sudden  flushing  of  the  face  is  frequently  to  be  observed. 
The  tache  cdrSbrale,  already  described,  may  generally  be  readily  produced. 
The  abdomen  almost  invariably  becomes  retracted  or  boat-shaped,  and  the 
body  generally  rapidly  emaciates.  Ptosis,  strabismus,  double  vision,  immo- 
bility of  pupil  or  of  eyeball,  or  facial  or  hypoglossal  paralysis,  may  come  on 
during  this  stage. 


376  GENERAL  DISEASES. 

The  third  stage  is  that  of  convulsions  and  coma,  or  of  coma  alone.  The 
temperature,  as  a  rule,  rises  higher  than  in  the  second  stage,  but,  on  the 
whole,  presents  great  irregularity.  The  coma  becomes  profound,  and  it  is 
impossible  to  rouse  the  patient  out  of  it.  He  rolls  his  head  from  side  to 
side,  tosses  his  hands  and  arms  restlessly  about,  picks  at  the  bedclothes, 
and  from  time  to  time  may  utter  the  characteristic  cry.  Convulsions  are 
frequent,  but  vary  in  intensity  and  extent,  and  may  be  altogether  absent. 
The  pupils  are  dilated,  unequal,  and  react  little  if  at  all  to  light. 

Paralysis  develops,  or,  if  previously  present,  now  becomes  more  pro- 
nounced. It  generally  affects  some  of  the  muscles  supplied  by  the  cranial 
nerves,  as  already  mentioned,  or  more  rarely  assumes  a  hemiplegic  form. 
There  is  usually  loss  of  control  over  the  sphincters.  Eigidity  of  the  limbs 
on  one  or  both  sides  is  often  present,  together  with  Kernig's  sign,  the 
inability  to  passively  extend  the  legs  when  the  thighs  are  flexed  at  a 
right  angle.  The  pulse  is  now  generally  quick  and  feeble,  although  some- 
times it  is  below  the  normal  rate.  Optic  neuritis  usually  occurs,  but  is 
seldom  intense,  although  it  gradually  becomes  more  marked  as  the  illness 
progresses.  Choroidal  tubercles  are  less  frequently  observed  when  optic 
neuritis  is  present  than  when  it  is  absent,  and,  on  the  whole,  are  less 
common  in  meningeal  than  in  other  forms  of  miliary  tuberculosis.  The 
usual  duration  of  the  illness  is  about  three  weeks.  It  may  be  added  that, 
in  the  case  of  adults,  prodromal  symptoms  are  rarely  observed,  a  sudden 
invasion  with  vomiting  or  convulsions  is  uncommon ;  emaciation  is  seldom 
a  marked  feature,  and  headache,  as  already  mentioned,  may  be  absent. 

Diagnosis. — The  diseases  with  which  acute  miliary  tuberculosis  is 
most  frequently  confused  are  acute  bronchitis,  broncho-pneumonia,  pneu- 
monia, enteric  fever,  and  acute  non-tuberculous  meningitis. 

The  pulmonary  form  may  be  mistaken  for  acute  bronchitis.  In 
tuberculosis  there  is,  as  a  rule,  more  marked  constitutional  disturbance. 
Dyspnoea  and  cyanosis  are  out  of  proportion  to  the  physical  signs.  The 
limitation  of  rales  to  one  lung,  or  their  rapid  dissemination  throughout 
both,  the  onset  with  haemoptysis  or  the  presence  of  rusty  sputa,  and  the 
existence  of  enlargement  of  the  spleen,  will  point  to  tuberculosis.  The 
character  of  the  pyrexia  may  help,  but  this  cannot  be  depended  on.  An 
"inverse  type,"  if  present,  is,  as  has  been  said,  specially  suggestive  of 
tuberculosis.  If  there  is  expectoration,  bacilli  should  be  looked  for,  but 
often  none  are  to  be  found.  An  ophthalmoscopic  examination  should  be 
made  for  choroidal  tubercle. 

Certain  cases  of  acute  pneumonia,  where  the  cerebral  symptoms  are 
out  of  proportion  to  the  pulmonary,  are  more  likely  to  be  mistaken  for 
tuberculosis  than  the  reverse.  The  doubt  is  not  likely  to  exist  for  long. 
The  sudden  onset,  the  existence  of  pain  in  the  side,  the  character  of  the 
pyrexia,  and,  above  all,  the  physical  signs  and  course  of  the  disease,  will 
generally  decide.  Henoch  is  inclined  to  believe  that  many  of  the  cases  of 
recovery  from  meningitis,  especially  from  tuberculous  meningitis,  have 
been  nothing  but  cases  of  pneumonia  with  cerebral  symptoms  which  were 
wrongly  diagnosed.  In  tuberculous  meningitis,  headache  persists  when 
delirium  comes  on,  whereas  in  general  diseases  it  ceases  with  the  onset 
of  delirium. 

Broncho-pneumonia  may  be  very  difficult  to  distinguish  from  acute 
pulmonary  tuberculisation.  The  sequence  of  the  former  affection  after 
measles  or  whooping-cough  may  help.  The  rapid  appearance  of  signs  of 
consolidation  points  to   broncho-pneumonia.     Fixity  of  the  rales  and  a 


TUBER  C  UL  OSIS.  3  7  7 

want  of  proportion  between  the  dyspnoea  and  the  physical  signs  are  in 
favour  of  tuberculosis. 

The  greatest  difficulty  has  existed  in  the  past  in  distinguishing 
between  acute  miliary  tuberculosis  and  enteric  fever.  The  method  of 
serum  diagnosis  should  be  applied  in  all  cases  of  doubt,  and  will  often  help 
to  clear  up  the  diagnosis.  In  differentiating  between  tuberculous  and  non- 
tuberculous  meningitis,  we  have  specially  to  consider  whether  there  exists 
any  cause  sufficient  to  account  for  the  latter  form. 

An  important  aid  in  the  diagnosis  of  all  forms  is  evidence  of  the 
presence  of  old  or  recent  foci  of  tubercle.  Unfortunately,  such  evidence 
is  not  often  available. 

Prognosis. — When  the  diagnosis  of  acute  miliary  tuberculosis  is 
certainly  established,  there  is  practically  no  hope.  A  few  cases  have  been 
recorded  where  recovery  has  occurred  from  meningitis,  which  there  has 
been  every  reason  to  believe  was  tuberculous,  but  they  are  so  few  that  they 
can  at  the  most  only  excite  a  shadow  of  doubt  as  to  the  result  in  the 
mind  of  the  physician.  I  have  never  seen  an  acute  case  recover  where  I 
have  found  choroidal  tubercle,  but  I  have  seen  a  patient  recover  in  whom 
all  the  usual  symptoms  including  optic  neuritis  were  present.  A  similar 
case  has  been  recorded  by  Samuel  West.  The  recovery  in  the  latter  was 
very  slow,  being  incomplete  at  the  end  of  nine  months.  During  the  child's 
illness  a  brother  died  of  tuberculous  meningitis. 

Treatment. — In  acute  miliary  tuberculosis,  treatment  can  only  be 
symptomatic.  If  there  is  constipation,  as  is  frequently  the  case,  calomel  is 
useful.  If  there  is  restlessness  and  pain,  opium  and  bromide  of  potassium 
in  small  doses  may  be  given  with  advantage.  If  there  is  distressing 
dyspnoea,  the  inhalation  of  oxygen  will  often  greatly  relieve.  If  the 
temperature  is  high,  sponging  with  tepid  or  cold  water,  cradling,  and  other 
modes  of  reducing  fever,  may  be  employed.  In  tuberculous  meningitis, 
special  measures  may  be  adopted,  such  as  the  application  of  cold  to  the 
head  by  means  of  an  ice-bag  or  otherwise,  counter  irritation  by  means  of 
blisters  or  mustard  plasters  applied  to  the  scalp  or  neck,  and  the  admini- 
stration of  mercury,  preferably  by  inunction. 

A  case  of  recovery  after  diagnostic  puncture  of  the  spinal  canal  in  the 
lumbar  region  has  been  recorded  by  Ereyhan.  In  this  case,  60  c.c.  of 
slightly  turbid  pale  serous  fluid  spurted  out,  in  the  sediment  of  which  fluid 
pus  corpuscles  and  tubercle  bacilli  were  found  The  patient  rapidly 
improved  after  the  puncture,  and  in  three  weeks  was  able  to  leave  bed.  In 
cases  under  my  own  care,  I  have  seen  only  temporary  if  any  relief  from 
this  measure.  Tapping  the  lateral  ventricles  has  also  been  tried  by 
myself  as  well  as  others,  but  has  failed  to  relieve. 

TUBEECULOSIS  OF  THE  ALIMENTAEY  SYSTEM. 

Mouth  and  Tongue. 

Morbid  anatomy. — Tuberculous  ulcers  are  very  rarely  found  on 
the  lips  and  gums.  The  fact  of  their  possible  occurrence  only  need  be 
mentioned.  Tuberculous  disease  of  the  tongue  is  of  more  importance,  and 
is  more  likely  to  come  under  the  observation  of  the  practitioner.  It  occurs 
more  frequently  in  men  than  in  women.  The  primary  form  is  extremely 
rare ;  the  secondary,  much  the  more  common,  is  nearly  always  met  with  in 
association  with  tuberculosis  of  the  lungs.     Eour  cases  of  secondary  tuber- 


37§  GENERAL  DISEASES. 

culous  ulceration  of  tongue  were  observed  among  531  fatal  cases  of  phthisis 
at  the  Brompton  Hospital.  The  most  likely  situation  for  it  is  at  or  near 
the  tip,  but  any  part  may  be  affected.  The  disease  starts  in  the  mucosa, 
where  one  or  more  granulations  appear,  and  perhaps  slightly  project  above 
the  surface 

Symptoms. — One  or  more  of  these  become  caseous,  and  an  irregularly 
shaped  ulcer  forms,  which  gradually  increases  in  size  and  depth.  The 
floor  of  the  ulcer  is  usually  uneven  and  granulated,  of  a  palish  pink  colour, 
and  often  coated  with  yellowish  grey  mucus.  The  edges  are  probably  a 
little  redder  than  the  surrounding  part  of  the  tongue.  They  are  generally 
sharply  cut,  but  may  be  bevelled,  as  a  rule  are  little  indurated  or  raised,  and 
are  seldom  everted  or  undermined.  In  the  neighbouring  portions,  which 
are  not  uncommonly  swollen,  there  are  often  little  tuberculous  nodules  of 
the  size  of  a  pin's  head,  of  a  pinkish  colour,  and  hard  to  the  touch,  and 
sometimes  little  yellowish  grey  points  even  tinier,  and  not  raised  above  the 
surface.  These  latter  are  very  characteristic  when  they  exist.  Scrapings 
of  the  floor  may  show  tubercle  bacilli.  The  submaxillary  and  submental 
glands  are  usually  but  not  always  enlarged.  The  ulcers  are  sometimes 
multiple.  Occasionally  the  ulceration  is  very  extensive,  as  in  two  cases 
reported  by  Morton,  where  ulceration  extended  from  the  frenum  to  the  tip 
on  the  under  surface.  Sometimes  much  destruction  of  tissue  is  produced, 
as  in  a  case  reported  by  Hale  White,  where  the  anterior  third  of  the  tongue 
had  been  destroyed  by  ulceration.  At  first  the  sore  is  indolent,  and  pain 
and  tenderness  are  absent,  though  both  are  present  later. 

Diagnosis. — The  difficulties  of  diagnosis  are  in  connection  with 
cancer  and  syphilis.  As  regards  the  sore  of  tertiary  syphilis,  this  is  more 
often  median  than  lateral.  There  is  more  tumour  formation,  the  floor  is 
deeper,  and  the  edges  are  undermined.  The  lymphatic  glands  as  a  rule  are 
not  affected.  Fournier  discusses  at  great  length  the  diagnosis  from  primary 
chancre  of  the  tongue.  The  latter  may  affect  any  part  of  the  tongue,  but  is 
unlikely  on  the  under  surface.  The  sore  is  indurated,  and  the  glands  are 
enlarged.  The  absence  of  induration  and  the  presence  of  nodules  or  yellow 
points  in  the  surrounding  tissue,  in  the  case  of  the  tuberculous  sore,  are 
very  important  distinguishing  features.  The  latter  may  also  assist  in  dis- 
tinguishing tubercle  from  epithelioma,  which  presents  great  difficulty,  for 
they  have  the  same  seat,  both  frequently  succeed  injury,  and  the  glands 
may  be  affected  in  both.  The  age  may  help  in  forming  an  opinion.  The 
examination  of  scrapings  of  the  floor  may  clear  up  the  diagnosis. 
Evidence  of  tuberculous  disease  in  the  lung  or  elsewhere  must  be  carefully 
sought  for. 

Prognosis  and  treatment. — The  disease  is  usually  fatal  in  a 
few  months,  or  at  longest  in  from  one  to  two  years.  The  lesion  progresses 
slowly,  and  sometimes  seems  to  be  temporarily  arrested  or  to  undergo 
healing,  but  the  disease  invariably  breaks  out  again.  If  primary,  the 
diseased  tissue  should  be  freely  removed ;  and  if  secondary,  limited  and 
small,  Butlin  considers  removal  still  gives  the  patient  the  best  chance. 
If  operation  is  not  considered  advisable,  non-irritating  applications  should 
be  used,  such  as  borax  and  chlorate  of  potash.  Cocaine  may  be  used  to 
relieve  pain.  After  cleaning  and  drying  the  ulcer,  one  may  dust  it  with 
a  powder  containing  iodoform  1  part,  borax  3  parts,  and  morphine  one- 
sixth  part. 


TUBERCULOSIS.  379 


Pharynx  and  Tonsils. 


Tubercle  sometimes  also  attacks  the  soft  and  hard  palate.  Greyish 
granulations  first  appear,  soon  succeeded  by  ulcers  having  yellowish  floors 
and, slightly  raised  edges  with  tubercles  on  the  margins.  There  is  usually 
a  general  swelling  of  the  parts  affected. 

'Tubercle  of  the  palate,  like  that  of  the  tongue,  is  nearly  always 
secondary  to  lung  disease ;  but  sometimes,  when  the  patient  is  first  seen, 
there  may  be  no  evidence  of  this,  as  in  a  case  I  had  the  opportunity  of 
observing  almost  from  its  beginning.  At  first  there  was  a  small  centrally 
situated  ulcer  on  the  roof  of  the  mouth,  with  a  caseous  floor,  and  discharging 
a  small  amount  of  pus.  There  were  no  tubercles  to  be  seen.  Other  ulcers 
soon  developed,  until  the  surface  of  the  hard  palate  became  almost  covered 
with  deep  ulcers  having  nodular  floors  and  caseating  centres.  Scrapings 
from  the  ulcers  showed  the  presence  of  tubercle  bacilli.  Later  there  was 
unmistakable  evidence  of  tubercle  at  the  apex  of  the  right  lung.  Laryn- 
goscopic  examination  showed  several  tubercles  on  the  epiglottis. 

The  tonsils  also  are  sometimes  tuberculous.  In  general  tuberculosis, 
there  may  be  a  number  of  grey  miliary  tubercles  in  the  superficial  layers 
of  the  mucosa,  or  situated  more  deeply  in  the  reticulated  follicular  tissue. 
In  the  chronic  type  the  superficial  tubercles  become  caseous,  forming 
opaque  yellowish  projections,  which  soon  ulcerate.  Tubercles  deeply 
situated  coalesce  and  form  a  caseous  mass,  surrounded  by  more  or  less 
general  tuberculous  infiltration.  Finally,  the  tonsil  may  be  reduced  to  a 
stump  formed  by  a  mass  of  tuberculous  tissue,  the  infiltration  extending  to 
the  neighbouring  connective  tissue  and  muscle. 

Some  recent  observations  show  that  the  tonsils  are  really  very  fre- 
quently tuberculous  in  cases  of  fatal  tuberculosis,  although  in  the  majority 
of  cases  there  is  no  naked  eye  evidence  of  tubercle.  Hugh  Walsham 
made  a  careful  microscopic  examination  of  the  tonsils  after  death  in 
twenty-four  cases  of  chronic  pulmonary  tuberculosis,  in  seventeen  of  which 
he  found  tubercles ;  and  in  seven  cases  of  acute  pulmonary  tuberculosis,  in 
four  of  which  he  found  tubercles.  In  these  cases  tubercles  were  generally 
in  the  miliary  form,  and  only  occasionally  was  there  evidence  of  com- 
mencing caseation.  They  varied  greatly  in  number  in  different  cases. 
Bacilli  were  usually  present,  but  scanty.  Walsham's  examinations  of 
enlarged  tonsils  and  adenoid  growths  removed  during  life  proved  negative. 

The  posterior  wall  of  the  pharynx  is  sometimes  infiltrated  and  ulcerated. 
When  this  occurs,  it  is  generally  in  connection  with  laryngeal  tubercle. 

Diagnosis. — The  difficulties,  as  in  the  case  of  the  tongue,  occur  in 
connection  with  syphilis  and  malignant  disease.  A  careful  examination  of 
the  lungs  and  of  the  sputum  will  probably  reveal  evidence  of  pulmonary 
tuberculosis,  if  the  lesion  is  tuberculous.  In  doubtful  cases,  scrapings 
should  be  examined  for  bacilli,  which  are  generally  to  be  found  in  tuber- 
culous cases. 

Prognosis  and  treatment.  —  The  prognosis  is  always  grave. 
The  presence  of  the  disease  interferes  with  mastication  and  deglutition, 
and  usually  is  in  itself  evidence  of  extensive  constitutional  affection.  The 
malady  tends  to  recur  if  the  ulcer  is  scraped  and  locally  treated.  In  all 
advanced  cases,  the  treatment  can  only  be  palliative.  If  there  is  pain, 
spraying  or  painting  with  cocaine  (before  food  will  make  mastication,  etc., 
more  tolerable.  If  the  case  is  seen  sufficiently  early,  and  the  disease  is 
limited,  an  attempt  may  be  made  to  remove  the  diseased  tissue  by  scraping. 


380  GENERAL  DISEASES. 

Unfortunately,  it  is  very  apt  to  recur,  on  account  of  the  great  difficulty  in 
effecting  a  thorough  removal.  As  in  the  case  of  the  tongue,  chlorate  of 
potash  and  borax  washes  may  be  employed,  and  the  ulcers  may  be  dusted 
with  the  iodoform,  morphine,  and  borax  powder.  Lactic  acid  may  also  be 
applied  in  the  mode  described  under  the  heading  of  Tuberculous  Disease  of 
Larynx. 

(Esophagus,  Stomach,  and  Duodenum 

Tubercle  of  the  oesophagus  is  not  common.  According  to  Cone,  up  to 
1897  only  forty-eight  cases  had  been  recorded.  Out  of  531  cases  of 
pulmonary  tuberculosis  at  Brompton,  tubercle  of  the  oesophagus  was  found 
twice;  in  one  case  in  the  form  of  discrete  tubercles,  in  the  other  of 
tuberculous  ulceration.  The  oesophagus  may  be  affected  by  extension  from 
disease  of  pharynx,  bronchial  glands,  or  other  neighbouring  structures,  by 
infection  of  pre-existing  lesion,  such  as  simple  or  malignant  ulcer,  by  blood 
infection,  or  by  inoculation  of  previously  healthy  mucosa  by  tuberculous 
sputum.  Occasionally  ulceration  of  the  oesophagus,  which  is  non-tuber- 
culous, is  met  with  in  phthisical  cases. 

Tuberculous  ulceration  of  the  stomach  is  not  so  uncommon  as  that  of  the 
oesophagus.  The  ulcers  are  almost  invariably  secondary.  They  may  arise 
by  extension  from  the  peritoneum,  or  through  a  general  blood  infection,  or 
from  ingested  tuberculous  material.  The  only  primary  case  I  know  of 
is  one  recorded  by  Orlandi,  in  which  there  was  primary  tuberculous  ulcera- 
tion of  the  pylorus,  extending  to  the  serous  coat  and  producing  some 
narrowing  of  the  orifice.  Proof  of  the  nature  of  the  disease  was  established 
by  inoculation,  as  well  as  by  microscopic  examination.  There  was  another 
area  of  tuberculous  infiltration  in  the  small  intestine,  but  no  evidence  of 
disease  elsewhere.  Ulcers  have  not  very  infrequently  been  met  with  in 
the  stomach  in  cases  of  tuberculosis,  but  usually  there  has  been  no  evidence 
of  tuberculous  deposit  in  their  floor  or  in  the  vicinity.  The  probability  is 
that  most  of  these  are  simple  ulcers.  Marfan,  in  1887,  concluded  that 
only  twelve  of  the  then  recorded  cases  of  tubercle  of  stomach  were  genuine. 
Forty -two  cases  of  tuberculous  ulcers  of  the  stomach  in  1180  autopsies 
on  tuberculous  children  have  been  recorded  in  literature.  Sometimes 
tuberculous  ulcers  of  the  stomach  are  multiple,  as  in  cases  reported  by 
Alice  Hamilton  and  W.  D.  Lister.  According  to  Marfan,  six  cases  of 
perforation  of  the  stomach  from  tubercle  have  been  observed,  but  always 
from  without  inwards.  Perforation  occurred  in  three  cases  from  a 
tuberculous  gland,  while  twice  it  was  the  result  of  peritoneal  tuberculosis, 
and  once  was  consecutive  to  a  tuberculous  ulcer  in  the  transverse  colon. 

Tuberculous  ulceration  of  the  duodenum  is  less  uncommon  in  adults 
than  that  of  the  stomach.  Nine  cases  were  met  with  among  531  autopsies 
on  cases  of  phthisis  at  Brompton. 

Intestine. 

Etiology. — Intestinal  tuberculosis  is  very  common  in  connection 
with  pulmonary  tuberculosis,  but  rare  apart  from  it.  In  1000  autopsies 
upon  tuberculous  subjects  at  the  Pathological  Institute  of  Munich,  in  567 
there  was  intestinal  tuberculosis,  but  only  one  of  these  was  primary.  Out 
of  1008  autopsies  in  cases  of  phthisis  at  the  Brompton  Hospital,  intestinal 
tuberculosis  was  met  with  in  707  cases,  or  in  701  per  cent,  of  the  whole. 
The  proportion  of  cases  is  sensibly  the  same  for  the  two  sexes,  unlike 


TUBERCULOSIS. 


38i 


laryngeal  tuberculosis.  Thus  69 '3  was  the  percentage  for  the  males,  and 
72-l  that  for  the  females. 

There  is  little  doubt  that  in  all,  or  nearly  all,  the  cases  of  phthisis  the 
affection  of  the  intestines  is  caused  by  the  swallowing  of  the  sputum.  We 
have  seen  how  readily  animals  are  rendered  tuberculous  when  fed  with 
tuberculous  material,  and  how,  in  such  cases,  the  lesions,  as  a  rule,  are  more 
marked  in  the  intestines  and  mesenteric  glands  than  elsewhere.  Tuber- 
culous milk  may  of  course  be  the  starting-point  of  infection  of  the  intes- 
tines, but  this  cause  will  account  for  a  very  small  proportion  of  the  cases. 

Soltau  Fenwick  and  Dodwell,  in  a  paper  founded  on  2000  necropsies 
at  the  Brompton  Hospital,  give  the  following  particulars  regarding  the 
cases  with  intestinal  tuberculosis : — 


Duodenum  affected 

in    3  "4  per  cent 

Jejunum          . 

„  28           „ 

Ileo-caecal  region 

.        „  85 

Ascending  colon 

•        „  51-4        „ 

Transverse  colon     . 

•        „  30-6        „ 

Sigmoid  flexure 

,,     lO'D           ,, 

Eectum          . 

•           „     14 

From  this  table  it  will  be  seen  that  in  85  per  cent,  of  the  intestinal 
cases  the  ileo-csecal  region  is  affected,  and  from  this  part  the  frequency  of 
the  disease  diminishes  in  both  directions.  The  caecum  is  the  part  most 
commonly  affected.  The  vermiform  appendix  is  affected  in  58  per  cent. 
In  about  two-thirds  of  the  intestinal  cases  examined  at  Brompton,  both 
the  large  and  small  intestine  were  affected;  in  about  a  fifth,  the  large 
intestine  alone ;  and  in  about  an  eighth,  the  small  intestine  alone. 

Morbid  anatomy. — The  forms  in  which  tubercle  is  usually  seen  in 
the  intestine  are  the  grey  miliary  tubercle,  or  the  larger  yellow  caseating 
tubercle,  and  ulcers  of  various  sizes  and  forms.  The  tubercles  are  generally 
seated  in  the  solitary  follicles  and  Peyer's  patches.  The  miliary  tubercles 
are  seldom  seen  alone,  but  occasionally  the  only  lesion  is  the  presence  of 
a  few  caseous  nodules  here  and  there.  The  tubercles  are  seated  in  the 
mucosa  or  in  the  glandular  structure  itself.  When  they  soften,  the  epi- 
thelium becomes  undermined  and  necrotic,  and  the  caseous  contents  are 
expelled,  a  small  cup-shaped  ulcer  being  formed  with  slightly  overhanging 
edges.  This  gradually  extends  in  depth  and  laterally.  In  Peyer's  patches 
the  process  generally  begins  in  separate  spots,  several  small  ulcers  being 
formed,  which  gradually  coalesce.  The  larger  ulcers  have  somewhat 
everted,  thickened  edges.  The  process  in  such  ulcers  is  a  slower  and  more 
gradual  one  than  in  those  with  undermined  edges.  The  floors  of  the  ulcers 
may  be  smooth  and  clean,  or  irregular  and  caseous,  being  as  a  rule  formed 
by  the  infiltrated  muscular  layer,  but  even  that  may  be  destroyed. 
Tubercles  may  often  be  seen  in  the  floors  and  on  the  peritoneal  aspect 
beneath  the  serous  membrane.  The  ulcers,  once  formed,  tend  to  spread: 
those  in  the  solitary  follicles,  by  extension,  coalesce  with  one  another,  and 
with  those  in  the  Peyer's  patches.  The  ulcers  thus  not  uncommonly,  instead 
L  of  being  longitudinal,  become  transverse  to  the  course  of  the  intestine. 

As  Treves  has  remarked, "  the  very  nature  of  the  tuberculous  process  and 
the  usual  progress  of  the  trouble  are  strongly  opposed  to  the  formation  of 
cicatricial  tissue."  Yet  it  sometimes  happens  that  strictures  result  from 
tuberculous  ulcers.  A  few  cases  have  been  recorded  by  Treves  and  others. 
Ulcers  in  the  jejunum  are,  as  a  rule,  few  and  far  between,  and  generally 
confined  to  its  lower  part.     The  amount  of  disease  present  in  the  ileum 


382  GENERAL  DISEASES. 

may  vary  from  one  or  two  small  ulcers  or  tubercles  to  a  very  wide 
destruction  of  the  mucous  membrane.  The  process  is  almost  invariably 
most  extensive  in  the  neighbourhood  of  the  ileo-caecal  valve.  The  caecum, 
it  has  been  pointed  out,  is  more  commonly  affected  than  any  other  part 
of  the  intestine,  and  sometimes  is  the  only  part  which  is  diseased.  When 
the  caecum  is  affected,  it  is  very  usual  for  the  vermiform  appendix  to  suffer 
also.  As  in  the  small  intestine,  so  in  the  large,  the  morbid  changes  may 
vary  from  a  few  small  tubercles  to  a  very  general  ulceration.  Both  the 
extent  and  frequency  of  disease  diminish  as  the  rectum  is  approached. 
In  the  rectum  the  ulcers  are  usually  of  small  size.  Haemorrhage  from  the 
floor  of  a  tuberculous  ulcer  is  decidedly  rare.  Intestinal  perforation  occurs 
in  a  little  over  1  per  cent,  of  all  fatal  cases  of  pulmonary  tuberculosis. 
Thus  it  was  met  with  twenty-five  times  in  2000  necropsies  at  Brompton. 
Of  these,  fifteen  terminated  in  acute  peritonitis,  and  ten  in  local  abscess. 
In  one  of  my  cases,  a  perforative  ulceration  of  the  appendix  led  to  a 
perityphlitic  abscess. 

Of  recent  years,  a  chronic  hyperplastic  form  of  intestinal  tuberculosis 
has  been  recognised.  It  is  characterised  by  great  thickening  of  a  limited 
portion  of  the  bowel  wall  and  narrowing  of  its  lumen.  It  has  been  met 
with  in  the  ileum,  but  most  frequently  occurs  in  the  caecum,  giving  rise  to 
a  carcinomatous-like  tumour. 

Fistula  in  ano  is  not  a  very  common  complication  of  tuberculosis,  and 
yet  a  large  proportion  of  the  sufferers  from  fistula  are  tuberculous.  The 
most  complete  statistics  on  the  subject  are  those  of  Spillmann,  who 
found  among  14,730  cases  of  phthisis,  523  of  fistula,  or  about  3-5  per  cent. 
Among  1680  of  my  out-patients  with  pulmonary  tuberculosis,  I  only  met 
with  twenty  cases  of  fistula,  giving  a  proportion  of  about  2  per  cent,  among 
males.  Among  626  phthisical  patients,  Hartmann  found  and  operated  on 
thirty-one  cases  of  fistula,  the  proportion  being  6  per  cent,  in  men  and 
3  "5  per  cent,  in  women.  Of  forty-eight  cases  of  fistula,  twenty-three  were 
tuberculous,  and  in  two  more  there  was  a  tuberculous  family  history. 
Allingham  gives  a  much  smaller  proportion.  Phthisical  symptoms  existed 
in  234  out  of  1632  cases  of  fistula,  or  in  little  over  14  per  cent.  Why 
tuberculous  fistula  should  affect  men  in  so  much  larger  proportion  than 
women,  is  not  explained.  The  incidence  we  have  seen  of  tubercle  in  the 
intestine  is  about  equal  in  the  two  sexes.  Ordinary  fistula,  moreover,  is  as 
common  in  women  as  in  men.  It  is  probable  that  in  tuberculous  cases  the 
fistula  begins  with  a  tuberculous  ulcer  in  the  rectum,  not  very  far  from  the 
anus,  and  in  connection  with  this,  an  abscess  forms  which  burrows  until  it 
finds  its  way  externally. 

Symptoms. — Miliary  intestinal  tubercle  will  produce  no  characteristic 
symptoms.  The  chief  symptom  of  tuberculous  ulceration  of  the  intestines 
is  persistent  diarrhoea,  the  occurrence  of  which  in  a  tuberculous  subject  is 
always  suggestive.  However,  in  some  cases  of  ulceration,  diarrhoea  never 
troubles  the  patient,  who  may  instead  suffer  from  constipation.  On  the 
other  hand,  tuberculous  patients  may  have  persistent  diarrhoea  without 
ulceration.  Pain  and  tenderness  in  the  abdomen  are  sometimes  experienced, 
but  cannot  be  said  to  be  characteristic. 

It  is  very  seldom  that  intestinal  tuberculosis  is  primary,  and  accord- 
ingly it  is  difficult  to  distinguish  the  symptoms  of  the  secondary  from 
those  of  the  primary  disease.  It  is  probable  that  pyrexia,  sweating, 
wasting,  etc.,  will  be  among  the  symptoms  met  with.  Frequently,  too,  the 
symptoms  of  peritoneal  tubercle  will  be  added  to  those  of  intestinal. 


TUBERCULOSIS.  383 

Diagnosis  and  prognosis. — If  one  can  ensure  that  the  patient 
does  not  swallow  any  sputum,  the  discovery  of  tubercle  bacilli  in  the  stools 
will  establish  the  nature  of  the  case.  There  is  a  very  strong  probability 
in  alL  cases  of  chronic  diarrhoea  in  tuberculous  subjects,  that  the  cause  is 
tuberculous  ulceration.  The  prognosis  is  very  unfavourable  when  ulcera- 
tion has  occurred.  The  possibility,  but  unlikelihood,  of  cure  is  shown  by 
the  rare  occurrence  of  healed  cicatricial  ulcers. 

Treatment. — It  is  very  important  in  all  cases  of  pulmonary  tuber- 
culosis to  ensure  that  the  patient  does  not  swallow  his  expectoration.  It 
is  still  important,  in  order  to  prevent  further  infection,  that  this  should 
be  impressed  on  him  when  ulceration  of  the  intestines  has  already  occurred. 
Little  can  be  done  in  the  way  of  checking  or  influencing  the  disease  when 
once  symptoms  have  become  marked.  It  should  be  borne  in  mind  that 
diarrhoea  is  not  simply  due  to  the  presence  of  ulceration,  but  to  the 
coexistence  with  the  ulceration  of  a  catarrhal  condition  of  the  intestine. 

When  the  diarrhoea  is  acute  and  accompanied  with  pain  and  tenderness, 
the  patient  must  be  kept  entirely  at  rest.  The  local  application  of  warm 
poultices  or  fomentations  will  probably  comfort  and  relieve.  The  diet  may 
consist  of  cold  boiled  milk  with  lime-water,  Benger's  food,  Savory  and 
Moore's  food,  or  other  prepared  malted  food,  and  whites  of  eggs,  either 
lightly  boiled  or  diluted  with  water  and  flavoured  with  orange  flower.  Eaw 
meat  will  sometimes  be  borne  well.  Isinglass,  well-boiled  rice,  and  arrow- 
root will  usefully  supplement  the  other  foods.  If  stimulants  are  indicated, 
old  brandy  or  port  wine  should  be  chosen.  Sherries  and  champagnes  should 
be  avoided.  Opium  is  a  most  valuable  drug,  and  may  be  given  alone  in  a 
liquid  or  solid  form,  or  in  combination  with  other  drugs.  Bismuth  stands 
only  second  to  opium.  Of  this,  the  most  generally  useful  preparation  is 
the  subnitrate  in  doses  of  10  to  20  grs.  made  up  with  mucilage  and  water, 
to  which  may  be  added  5  or  10  minims  of  tincture  of  opium  or  liquor 
opii  sedativus,  and  a  drachm  of  tincture  of  catechu.  The  salicylate  of 
bismuth  is  preferred  by  some,  as  combining  antiseptic  properties  with  the 
special  local  action  of  bismuth.  Its  dose  is  the  same  as  that  of  the 
subnitrate.  Sometimes  at  the  outset  it  is  well  to  administer  an  aperient, 
in  order  to  rid  the  intestine  of  any  irritating  substances.  For  this  purpose 
a  grain  of  calomel,  followed  by  a  small  dose  of  castor-oil,  is  valuable.  If 
the  symptoms  abate,  the  dietary  can  be  gradually  improved,  and  the  opium 
and  bismuth  diminished  or  withdrawn. 

In  chronic  cases,  a  too  rigid  dietary  need  not  be  enforced,  but  the 
patient  should  be  forbidden  fruit,  green  vegetables,  and  all  articles  of  food 
likely  to  fret  and  irritate  the  intestines  or  to  increase  any  tendency  to 
diarrhoea.  Tea,  coffee,  and  beef-tea  are  generally  better  dispensed  with. 
The  preparations  of  bismuth  and  opium,  already  mentioned,  are  likewise 
valuable  in  chronic  cases.  The  subgallate  of  bismuth  (dermatol)  is  a  useful 
astringent,  and  may  possibly  succeed  in  doses  of  8  to  20  grs.  when  other 
preparations  fail.  A  remedy  which  sometimes  relieves  the  diarrhoea  is 
sulphate  of  copper.  A  quarter  of  a  grain  of  sulphate  of  copper,  with  half 
a  grain  of  opium,  may  be  given  once  or  twice  a  day.  Kino,  in  the  form  of 
the  pulv.  kino  co.,  may  also  be  tried  in  doses  of  5  grs.  Cotoin  in  2  gr. 
doses  in  pill  form  or  suspended  in  water  and  mucilage  has  occasionally 
proved  useful.  Sometimes  the  combination  of  lead  and  opium,  as  in  the 
pil.  plumb,  c.  opio,  will  relieve. 

Tannigen  and  tannalbin,  both  derivatives  of  tannin,  are  astringents 
which  have  lately  been  used  in  these  cases.     They  are  given  in  doses  of 


384  GENERAL  DISEASES. 

10  to  20  grs.  three  times  a  day.  Dilute  sulphuric  acid,  in  doses  of  15  to 
20  minims,  may  also  be  tried.  No  rules  can  be  laid  down  as  to  which  of 
these  remedies  will  suit  in  individual  cases.  I  have  mentioned  them  in 
the  order  in  which  I  have  myself  found  them  useful.  Sometimes  they  all 
fail,  sometimes  one  will  succeed  where  the  others  have  not  benefited. 

In  all  forms  of  diarrhoea,  but  especially  where  it  depends  on,  or  is 
associated  with,  ulceration  of  the  rectum,  morphiue  suppositories,  or  starch 
and  opium  enemata,  may  give  more  relief  than  anything  else.  As  recom- 
mended by  Walshe,  enemata  of  nitrate  of  silver,  1  to  3  grs.  dissolved  in 
4  oz.  of  water,  may  also  have  a  beneficial  influence. 

Inguinal  colotomy  has  been  recommended  in  severe  tuberculous  ulcera- 
tion of  the  rectum.  In  anal  fistula  there  should  be  thorough  opening  up 
and  treating  from  below. 

Liver  and  Pancreas. 

The  liver  is  generally  the  seat  of  miliary  tubercles  in  acute  general 
miliary  tuberculosis.  These  bodies  are,  however,  as  a  rule,  not  visible  to 
the  naked  eye,  although  sometimes  a  few  of  the  larger  ones  may  be  seen  on 
the  surface  or  in  a  section  as  greyish  white  masses  as  large  as  a  pin's  head. 
The  formation  of  caseous  tuberculous  masses  in  the  liver  is  so  rare  as  to  be 
a  pathological  curiosity.  Occasionally  the  liver  becomes  honeycombed  with 
innumerable  cavities,  varying  in  size  from  a  pea  to  a  walnut,  and  filled  with 
softened  bile-stained  materials,  while  the  walls  contain  tubercles.  This 
form  of  disease  is  attributed  to  tuberculous  affection  of  the  bile-ducts. 

A  few  cases  have  been  recorded  in  which  tuberculous  abscesses  have 
formed  in  the  liver,  varying  from  the  size  of  a  chestnut  to  that  of  a  large 
orange.  In  a  case  which  I  have  recorded,  there  was  an  abscess  the  size  of 
an  orange,  containing  soft  pultaceous  matter,  surrounded  by  smaller  caseous 
masses.  There  was  thickening  of  the  capsule  of  the  liver,  with  contrac- 
tion. There  were  tubercles  with  giant  cells  in  the  walls,  and  tuberculous 
disease  of  lungs.  Similar  cases  have  been  recorded  by  Wethered  and 
Mayo  Eobson.  Some  of  the  cases  formerly  recorded  as  scrofulous  abscess 
of  liver  are  now  recognised  as  cases  of  actinomycosis.  The  pancreas,  like 
the  liver,  is  very  rarely  the  seat  of  caseous  or  chronic  tuberculosis.  One 
case  has  been  recorded  by  Ormerod  where  there  were  two  or  three  small 
caseous  patches,  as  well  as  a  cavity  which  contained  broken-down  caseous 
substance. 


TUBEECULOSIS  OF  THE  LYMPHATIC  SYSTEM. 
Lymphatic  Glands. 

The  identity  of  scrofula,  or  the  enlarged  caseating  and  suppurating 
glands  met  with  in  the  neck  and  elsewhere,  with  tubercle,  although  main- 
tained by  Laennec  and  Villemin,  was  only  firmly  established  when  it  was 
shown  by  Koch  that  the  condition  depended  on  the  tubercle  bacilli.  Arloing 
has  attempted  to  show  that  in  scrofula  the  virus  exists  in  an  attenuated 
form,  arguing  from  the  fact  that  scrofulous  matter  does  not  infect  rabbits, 
although  it  does  guinea-pigs.  It  has  been  conclusively  shown  that  there  is 
no  real  difference  in  the  virus,  except  that  of  quantity,  the  caseous  matter 
from  the  scrofulous  cervical  or  other  glands  being  poor  in  bacilli,  while  that 
from  the  ordinary  pulmonary  lesions,  etc.,  is  rich.     As  already  stated,  for 


TUBERCULOSIS.  385 

an  inoculation  experiment  to  be  successful,  there  is  a  minimum  number  of 
bacilli  requisite,  and  no  change  is  produced  with  a  less  number. 

Etiology  and  morbid  anatomy. — The  lymphatic  glands,  par- 
ticularly in  the  young,  have  a  special  liability  to  infection  by  tubercle.  In 
897  cases  of  tuberculosis  in  children,  which  I  have  collected,  the  lymphatic 
glands  were  affected  in  792,  or  in  88  per  cent.,  rather  more  than  seven- 
eighths  of  the  whole.  It  was  maintained  by  Parrot  that,  in  the  case  of 
the  bronchial  glands,  the  disease  was  always  secondary  to  a  pulmonary 
lesion,  and  further,  that  the  condition  in  the  lung  was  practically  repro- 
duced in  the  gland.  It  is  certain,  however,  that  at  any  rate  in  the  case  of 
children,  the  bronchial  glands  may  be  tuberculous  without  any  tubercle 
being  present  in  the  lungs.  It  is  common  to  find  caseous  bronchial  glands 
in  cases  of  tuberculous  meningitis  and  general  miliary  tubercle.  It  seems 
clear,  too,  that  disease  in  the  lungs  may  be  consecutive  to  disease  in  the 
bronchial  glands.  The  observations  of  Loomis  and  Pizzini,  who  found  that 
apparently  normal  bronchial  glands  of  people  dying  from  diseases  other 
than  tuberculosis  produced  tubercle  by  inoculation,  require  confirmation. 

The  lymphatic  glands  may  become  primarily  infected  in  various  ways 
— the  cervical  from  the  bacilli  entering  by  the  mouth  and  reaching  the 
glands  through  the  tonsils  or  some  spot  in  the  interior  of  the  buccal  cavity 
of  little  resistance ;  the  bronchial  through  inhalation  and  the  entrance  of 
the  bacilli  by  means  of  the  lung ;  the  mesenteric  through  ingestion,  the 
bacilli  being  swallowed  in  the  sputa  or  in  milk  or  some  other  form  of  food, 
and  passing  from  the  intestine  to  the  glands.  In  all  these  cases  the  glands 
may  become  affected  without  there  being  any  actual  tuberculous  lesion  at 
the  spot  where  the  bacilli  have  entered.  Probably  infection  is  often 
carried  to  the  glands  by  the  blood,  and,  as  Watson  Cheyne  suggests, 
infection  may  follow  on  a  non-specific  inflammation. 

Of  the  various  glands,  the  most  common  to  be  affected  in  children,  as 
well  as  in  adults,  are  the  bronchial.  Moreover,  as  often  happens  when  the 
bronchial  glands  are  affected  along  with  the  mesenteric,  the  disease  in  the 
former  is  usually  more  extensive  and  further  advanced.  This  points,  as 
we  have  before  remarked,  to  inhalation  as  probably  the  common  mode  of 
infection  in  children,  as  well  as  in  adults.  Whether  the  affected  glands  are 
bronchial,  mesenteric,  cervical,  or  other,  the  morbid  condition  is  the  same, 
and  may  conveniently  be  described  here.  The  glands  are  swollen,  soft, 
and  of  a  greyish  pink  colour  in  the  early  stage,  while  later  they  may 
be  firm  and  pigmented.  On  section,  grey  or  yellow  tubercles  or  spots 
of  softening  may  be  visible,  but  sometimes  the  tubercles  are  of  too 
minute  size  to  be  recognised,  except  with  the  aid  of  the  microscope. 
Sometimes  the  general  swelling  of  the  gland  is  simply  inflammatory,  but 
more  commonly  it  consists  of  a  tuberculous  infiltration.  Partial  or  general 
caseation  of  the  tuberculous  gland  is  the  rule,  but  the  fibrous  change  may 
supervene  without  caseation  having  occurred,  and  the  gland  becomes 
indurated  and  much  pigmented,  and  contracts.  Caseation  may  appear 
simultaneously  at  a  number  of  separate  foci,  and  spread  until  a  large 
area  or  the  whole  of  the  gland  is  caseous.  The  caseous  matter  may 
soften,  and  the  whole  gland  may  have  a  pus-like  consistency.  The  gland 
becomes  adherent  to  the  surrounding  tissue,  and  the  matter  may  burrow 
in  various  directions.  Provided  no  other  change  supervenes,  the  caseous 
gland  may  become  calcareous.  This  change  is  common  in  the  case  of  the 
bronchial  and  mesenteric  glands. 

Symptoms. — The  affection  of  the  glands  may  be  general  or  locaL 
vol.  1. — 25 


386  GENERAL  DISEASES. 

General  tuberculous  adenitis. — It  occasionally  happens  that  there  is 
a  general  affection  of  the  glands  throughout  the  body,  a  general  tuberculous 
adenitis.  This  form  of  disease,  to  which  special  attention  has  been  drawn 
by  Fagge  and  Osier,  is  usually  met  with  in  adults,  and  runs  a  rapid  and 
progressive  course.  It  is  decidedly  uncommon,  and  no  typical  case  of  it 
has  been  met  with  to  my  knowledge  at  St.  Thomas's  Hospital  during  the 
last  sixteen  years.  Osier  states  that  it  is  more  common  in  the  negro  than 
in  the  white. 

The  glands  most  likely  to  be  affected  are  the  axillary,  cervical,  bronchial, 
mesenteric,  retroperitoneal,  and  inguinal.  These  may  be  much  enlarged  and 
caseous,  while  the  various  organs  show  little  or  no  tubercle.  The  spleen,  how- 
ever, is  usually  enlarged,  and  may  contain  yellow  caseous  masses.  Fever, 
which  may  be  high,  is  generally  present,  and  the  patient  rapidly  emaciates. 
The  duration  of  the  malady  is  from  six  months  to  a  year.  Clinically,  there 
is  great  difficulty  in  distinguishing  it  from  lymphadenoma. 

Local  tuberculous  adenitis.  —  Cervical.  —  The  cervical  glands  very 
frequently  become  affected  with  tubercle  in  children,  and  sometimes  also 
in  adults.  It  was  this  form  of  the  disease  which  was  formerly  described 
as  scrofula.  It  is  very  common  among  the  ill -fed  and  badly-housed  poor, 
and  large  numbers  of  such  cases  come  under  treatment  year  by  year  at 
the  hospitals.  The  disease  in  children  is  more  often  purely  local,  and  unac- 
companied by  tuberculous  lesions  in  the  internal  organs  than  otherwise  ;  but 
in  adults  it  is,  in  my  experience,  frequently  associated  with  signs  of  disease 
in  the  lungs.  Marfan  believes  that  the  so-called  scrofula  has  a  protective 
influence  against  pulmonary  tuberculosis ;  but  my  own  experience,  like 
that  of  many  others  who  see  much  of  the  latter  disease,  does  not  support 
this  view.  It  is  true  that  many  who  have  had  tuberculous  glands  in 
childhood  never  become  phthisical ;  but,  judging  from  the  frequency  with 
which  one  finds  evidence  of  old  scrofula  among  the  phthisical,  one  cannot 
accept  the  protective  theory. 

The  glands  first  enlarged  are  generally  the  submaxillary.  These 
gradually  increase  in  size,  and  are  at  first  isolated,  but  later  form  nodular 
tumours.  In  about  half  the  cases  the  enlarged  glands  suppurate,  the  skin 
becomes  adherent,  and  an  abscess  opens  spontaneously  externally,  unless 
incised.  They  are,  as  a  rule,  neither  painful  nor  tender  until  there  is 
suppuration  and  tension  of  the  skin.  They  often  progress  very  slowly. 
When  they  suppurate  and  communicate  with  the  surface,  they  may  go 
on  discharging  for  a  long  time. 

The  treatment  of  such  cases  generally  comes  within  the  province  of 
the  surgeon.  If  there  is  an  abscess,  it  should  be  opened.  When  the 
enlargement  is  considerable,  and  suppuration  is  suspected,  it  is  generally 
best  to  remove  the  glands  as  thoroughly  as  possible ;  but,  on  account  of 
their  position  and  relations,  it  i£  not  always  practicable  to  remove  the 
whole  disease.  Cod-liver  oil,  arsenic,  good  food,  and  bracing  seaside  air,  such 
as  that  of  Margate,  have  sometimes  a  favourable  influence  on  the  course  of 
the  disease,  and  the  enlargement,  after  lasting  some  months,  subsides,  and 
the  patient  gets  well.  The  fewness  of  the  bacilli  in  these  cases  is  pro- 
bably the  reason  why  general  infection  is  decidedly  uncommon.  If  the 
expectant  method  of  treatment  is  adopted,  the  patient  should  be  closely 
watched. 

Bronchial. — The  bronchial  glands  probably  come  next  to  the  lungs  as 
regards  the  frequency  with  which  they  become  tuberculous.  They  are 
affected  in  about  80  per  cent,  of  all  cases  of  general  tuberculosis,  and  in 


TUBER  C  UL  OSIS.  3  S  7 

about  40  per  cent,  of  chronic  cases.  The  glands  most  frequently  affected 
are  those  situated  just  below  the  bifurcation  of  the  trachea.  When  a 
tuberculous  gland  is  embedded  in  the  lung,  it  may  be  difficult  to  distinguish 
it  from  a  diseased  portion  of  lung. 

Various  symptoms  have  been  attributed  to  tuberculous  bronchial 
glands,  especially  crowing  breathing,  a  paroxysmal  cough,  and  vomiting, 
supposed  to  be  due  to  irritation  of  the  pneumogastric.  Asthmatic  attacks 
have  been  observed  from  pressure  on  the  trachea  or  bronchus.  Collapse 
of  lung  has  also  ensued.  When  the  glands  are  large,  any  of  the  symptoms 
met  with  in  mediastinal  tumour  may  be  present.  Earely  a  caseous  gland 
perforates  the  trachea  and  causes  fatal  dyspnoea.  The  same  accident  has 
happened  in  the  case  of  the  oesophagus,  the  pericardium,  the  pulmonary 
artery,  and  even  the  aorta,  which  have  all  at  times  been  perforated  by 
caseous  bronchial  glands. 

Mesenteric, — Similar  changes  to  those  just  mentioned  in  the  bronchial 
glands  are  frequent  also  in  the  mesenteric,  and  are  often  associated  with 
tubercle  of  the  intestines  and  peritoneum.  The  symptoms  present  are 
wasting  and  diarrhoea,  with  enlargement  of  the  abdomen,  in  which  nodules 
may  be  felt.  They  are  more  fully  discussed  in  the  section  on  tuberculous 
peritonitis.  Perforation  of  the  intestine  sometimes  occurs  through  a 
caseous  mesenteric  gland  ulcerating  through  from  without  inwards.  Just 
as  obsolete  tubercle  is  unexpectedly  met  with  in  the  bronchial  glands,  so 
it  is  in  the  mesenteric.  Sometimes  one  finds  calcareous  masses  as  large  as 
a  pigeon's  egg,  and  smaller  masses  are  not  uncommon. 

Spleen. 

The  spleen  is  very  commonly  affected  in  general  miliary  tuberculosis, 
especially  in  young  children.  It  becomes  moderately  enlarged.  Grey 
miliary  tubercles  are  most  easily  recognised  on  the  surface.  Caseous 
tubercles  may  be  more  or  less  numerous,  varying  in  size  from  a  millet 
seed  to  a  hazel  nut. 

Lymphatics. 

As  it  is  by  means  of  the  lymphatics  that  the  bacillus  reaches  the 
glands,  it  is  to  be  expected  that  the  former  should  themselves  sometimes 
be  affected  with  tuberculosis.  It  was  pointed  out  long  ago  that  in  the 
case  of  tuberculous  ulcers  of  the  intestine  there  are  often  to  be  seen  on 
the  serous  surface  little  granulations,  from  whence  proceed  rows  of  similar 
bodies,  arranged  like  the  beads  of  a  necklace.  These  follow  the  course 
of  the  lymphatics,  of  which  they  occupy  the  wall,  and  end  in  caseous 
glands.  Similar  granulations  have  been  observed  in  the  lymphatics  of  the 
pleura  in  connection  with  lesions  in  the  lung. 

It  is  in  the  subcutaneous  lymphatics  that  the  most  interesting  tuber- 
culous lesions  have  been  met  with.  These  are  nearly  always  secondary  to 
such  cutaneous  inoculations  as  anatomical  tubercle,  warty  tuberculosis, 
etc.  Three  cases  are  recorded  where  the  primary  cause  was  cutaneous 
tubercle  of  the  finger,  contracted  by  women  while  nursing  phthisical  hus- 
bands. They  occasionally  but  rarely  result  from  deep  tuberculous  lesions  of 
the  bones. 

At  intervals  along  the  superficial  lymphatics  there  are  tumours,  at  first 
small,  but  gradually  increasing  to  the  size  of  a  walnut  or  even  a  Tangerine 
orange.     At  first  the  skin  is  movable  over  them,  and  they  are  hard.     As 


388  GENERAL  DISEASES. 

they  increase  in  size  they  soften  and  raise,  redden  and  thin  the  skin,  through 
which  they  gradually  ulcerate,  and  discharge  thin  grumous  pus,  which 
contains  few  bacilli.  There  may  or  may  not  be  a  hard  cord  uniting  the 
abscesses.     The  glands  may  be  tuberculous  also. 

Eve  has  recorded  a  very  typical  case,  in  which  there  were  three  super- 
ficial fluctuating  swellings  in  linear  series  along  the  forearm,  in  addition  to 
one  on  the  dorsum  of  the  hand.  The  abscesses  tend  to  recur,  and  in  several 
of  the  recorded  cases  the  patients  ultimately  died  of  phthisis. 

TUBERCULOSIS  OF  THE  VASCULAE  SYSTEM. 

Tubercle  of  the  heart  is  uncommon.  Miliary  tubercle  is  sometimes 
seen  on  the  surface,  and  rarely  on  the  interior  in  cases  of  generalised 
tubercle.  The  conus  arteriosus  is  a  seat  of  election.  Caseous  masses  are 
very  rare.  Cases  of  tuberculous  endocarditis  have  been  recorded  by 
Lancereaux  and  Benda. 

Tuberculous  phlebitis  and  endarteritis  have  been  frequently  observed  in 
acute  miliary  tuberculosis.  Weigert  found  the  condition  in  thirteen  out  of 
fourteen  cases  of  this  disease,  commonly  in  the  pulmonary  veins.  Mugge, 
in  nine  cases  out  of  ten,  found  tuberculous  granulations  in  the  internal 
tunic  of  the  pulmonary  artery,  as  well  as  in  the  pulmonary  veins.  Hanau 
found  the  same  condition  in  eight  out  of  thirteen  cases.  Turner  recorded 
a  case  in  which  there  were  clusters  of  minute  granulations  on  four 
divisions  of  the  pulmonary  artery. 

Cornil  has  observed  a  thickening  of  the  intima  with  the  new  formation 
of  a  great  number  of  cells  of  varied  form,  and  among  them  numerous  and 
very  large  giant  cells.  In  consequence  of  the  thickening  of  the  intima  the 
vessels  become  gradually  blocked.  Tuberculous  growths  have  been  met 
with  in  the  large  blood  vessels,  but  are  decidedly  rare.  In  a  few  cases  the 
aorta  has  been  involved  by  direct  extension  from  a  tuberculous  lesion 
external  to  the  vessel.  In  other  cases,  tuberculous  nodules  have  been  found 
growing  from  the  intima  and  projecting  into  the  lumen  of  the  aorta.  In 
the  reported  cases,  these  have  been  few  and  of  small  size,  seldom  larger 
than  a  pin's  head. 

TUBEECULOSIS  OF  THE  SEEOUS  MEMBEANES. 

Pleura. 

Tuberculous  pleurisy  has  of  late  years  been  recognised  to  be  a  much 
commoner  disease  than  was  at  one  time  supposed.  Many  of  the  cases 
formerly  described  as  simple  idiopathic  pleurisy,  are  now  known  to  be  really 
tuberculous.  Some  authorities,  especially  those  of  the  French  school,  go 
so  far  as  to  assert  that  pleurisy  a  frigore  does  not  exist.  Germain  See, 
probably  expresses  the  truth,  when  he  says  that  tuberculosis  is  the  most 
usual  cause  of  the  so-called  simple  pleurisy,  and  represents  the  real  cause 
in  three-fourths  of  the  cases. 

Etiology,  pathology,  and  morbid  anatomy. — The  evidence 
as  to  the  nature  of  simple  idiopathic  pleurisy  rests  on  the  results  of  post- 
mortem examinations  ;  the  examination  of  the  exudation  for  bacteria,  and 
the  results  obtained  by  inoculating  animals  with  the  fluid ;  the  result  of 
the  employment  of  tuberculin  in  patients  affected  by  simple  pleurisy;  and. 
the  subsequent  history  of  the  patients  who  have  had  an  attack  of  pleurisy. 


TUBERCULOSIS.  389 

The  evidence  of  the  post-mortem  room.  Simple  idiopathic  pleurisy 
very  seldom  proves  fatal,  and  on  this  account  the  evidence  forthcoming 
from  the  post-mortem  room  as  to  its  nature  is  very  limited.  During  twelve 
years,  531  cases  were  admitted  to  St.  Thomas's  Hospital  for  pleurisy.  Of 
these  only  fourteen  died,  of  which  three  were  complicated  with  pneumonia, 
one  with  pericarditis,  and  one  was  secondary  to  cardiac  disease.  Of  the 
remaining  nine,  four  were  certainly  tuberculous.  Kelsch  and  Vaillard 
found  tubercle  present  in  the  pleura  in  sixteen  cases  of  what  clinically 
appeared  to  be  simple  idiopathic  pleurisy,  in  most  of  which  the  lungs  were 
free  from  tubercle.  Osier  carefully  analysed  the  post-mortem  records  of 
101  cases  from  his  wards,  in  which  pleurisy — fibrinous,  sero-fibrinous, 
hemorrhagic,  or  purulent — was  found,  and  of  these  there  were  thirty-two 
in  which  the  pleurisy  was  definitely  tuberculous.  In  Osier's  cases,  however, 
the  pleurisies  were  for  the  most  part  secondary  to  acute  diseases  of  the 
lungs,  or  occurred  as  terminal  processes  in  chronic  affections  of  the  heart, 
arteries,  or  kidneys. 

The  serous  effusion  from  a  case  of  idiopathic  pleurisy  is  nearly 
always  found  to  be  sterile,  and  apparently  free  from  micro-organisms.  The 
results  of  the  inoculation  of  animals  with  the  fluid  show,  however,  con- 
clusively that  the  tubercle  bacillus,  or  its  spores,  if  such  exist,  must  in 
many  cases  be  present  in  the  fluid.  The  same  difficulty  has  been  experienced 
in  discovering  bacilli  in  milk  where  inoculation  experiments  have  pointed 
to  their  presence. 

Inoculation  does  not  always  succeed  in  producing  tuberculosis,  even 
when  the  pleurisy  is  undoubtedly  tuberculous.  Kelsch  and  Vaillard,  as 
well  as  Gilbert  and  Lion,  have  recorded  failure  in  cases  subsequently 
proved  to  be  tuberculous  at  the  post-mortem  examination.  Netter  found 
that  out  of  sixteen  cases  certainly  tuberculous,  only  eight  gave  positive 
results.  In  twenty-five  cases  of  what  were  considered  to  be  ordinary 
pleurisy,  he  succeeded  ten  times  in  inducing  tuberculosis.  He  does  not 
mention  the  amount  used  for  injection,  which,  when  dealing  with  a 
fluid  in  which  tubercle  bacilli  are  extremely  few,  is  a  matter  of  great 
importance. 

Chauffard  and  G-ombault  injected  into  the  peritoneal  cavities  of  guinea- 
pigs  3  c.c.  of  serum  from  cases  of  pleurisy,  and  found  that  the  fluid,  in  ten 
out  of  twenty  cases,  produced  tuberculosis.  Aschoff  has  recently  obtained 
still  more  striking  results.  He  also  injected  3  c.c.  of  the  serum  into  the 
peritoneal  cavity.  Out  of  twenty-five  cases  where  the  pleurisy  was  either 
certainly  or  probably  tuberculous,  eight  gave  a  negative  result,  or  32  per  cent. 
Out  of  twelve  idiopathic  cases,  only  three  gave  a  negative  result,  or  25  per 
cent.  The  experiments  of  Eichhorst  go  to  show  that  the  larger  the  amount 
of  serum  used  for  injection,  the  smaller  is  the  proportion  giving  negative 
results.  When  1  c.c.  of  fluid  was  injected  into  the  peritoneal  cavity  of 
guinea-pigs,  in  ten  out  of  eleven  cases  the  animals  remained  healthy,  in 
the  other  a  tuberculous  affection  of  the  lymphatic  glands  was  caused.  As 
in  some  of  the  negative  cases  tuberculosis  was  suspected,  in  later  experi- 
ments larger  quantities,  as  much  as  15  c.c,  were  used  for  injection.  When 
this  was  done,  fifteen  out  of  twenty-three  guinea-pigs  were  infected,  or  65 
per  cent.  In  other  words,  two-thirds  of  the  cases  of  serous  pleurisy  proved 
to  be  tuberculous. 

The  amount  of  evidence  as  to  the  tuberculous  nature  of  pleurisy 
through  the  use  of  tuberculin  is  small.  The  official  report  of  the  Prussian. 
Government  on  tuberculin  contains  the  accounts  of  fifteen  cases  of  pleurisy 


39°  GENERAL  DISEASES. 

injected  with  it.  Thirteen  of  these  reacted.  This,  of  course,  does  not 
justify  the  conclusion  that  the  pleurisy  itself  was  tuberculous,  but  it  shows 
the  probable  presence  of  tubercle  in  a  very  striking  proportion  of  the  cases 
of  pleurisy  tested.  Osier  mentions  an  instance  where  a  marked  reaction 
from  tuberculin  led  to  a  wrong  diagnosis,  the  ca'se  eventually  turning  out 
to  be  one  of  cancerous  pleurisy. 

It  has  been  observed  by  various  physicians  that  a  considerable 
proportion  of  patients  who  have  suffered  from  pleurisy,  later  on  are 
attacked  by  tuberculous  disease  of  lung.  Fagge  remarked  how  one  is 
frequently  seeing  patients  who,  having  favourably  passed  through  an 
attack  of  pleurisy,  are  shortly  afterwards  seized  with  haemoptysis,  or  show 
signs  of  tuberculous  disease  of  the  lungs.  Barrs  of  Leeds,  in  1890,  traced 
the  subsequent  history  of  fifty-seven  patients  treated  for  pleurisy  in  the 
Leeds  Infirmary  between  1880  and  1884.  He  found  that  thirty-two  were 
dead,  and  eighteen  of  these  were  ascertained  to  have  died  from  tuberculosis. 
Ziemssen  says  that  of  adults  who  have  lived  through  a  chronic  pleurisy 
nearly  one-half  die  of  tubercle.  Statistics  similar  to  those  of  Barrs  have 
been  brought  forward  by  Fiedler,  Bicochon,  and  Bowditch. 

Fiedler's  statistics  are  founded  on  112  cases  which  were  aspirated  by 
him  at  Dresden.  Of  these,  twenty-five  died  of  tuberculosis,  sixty-six 
became  certainly  or  probably  tuberculous,  and  only  twenty-one  were  in 
good  health  one  or  two  years  after.  Bowditch's  statistics  are  of  great 
interest,  because  they  were  drawn  from  cases  in  private  practice,  and 
embrace  an  experience  extending  over  many  years.  Out  of  forty-nine 
cases  of  pleurisy  seen  between  1849  and  1869,  twenty-two  died  from 
phthisis;  and  of  forty-one  seen  between  1869  and  1879  there  were  ten 
deaths  from  phthisis.  As  the  investigation  was  made  in  1889,  sufficient 
time  had  probably  not  elapsed  in  the  cases  in  the  last  decade  to  allow  for 
the  evolution  of  the  proper  quota  of  cases  of  phthisis.  These  statistics  bring 
out  prominently  enough  the  frequency  with  which  phthisis  follows  an 
apparently  simple  pleurisy,  and  strongly  support  the  view  that  the  pleurisy 
was  itself  tuberculous. 

That  empyemata  are  sometimes  tuberculous  is  well  known,  but  they  are 
less  commonly  so  than  simple  serous  pleurisies.  According  to  Netter,  25 
per  cent,  of  empyemata  in  the  adult  are  tuberculous,  and  6-5  per  cent,  in 
the  child. 

Tubercle  bacilli  are  less  difficult  to  stain  and  discover  in  purulent 
effusions  than  in  serous — a  fact  which  has  been  explained  by  supposing 
that  in  the  former  the  bacilli  are  set  free  from  the  tuberculous  ulcers  of  the 
pleura,  while  in  the  latter  they  are  retained  in  the  fibrin,  which  coagulates 
on  the  walls.  Still  their  discovery  involves  great  technical  skill  and 
patience.  Ehrlich  has  found  bacilli  in  each  one  of  a  series  of  cases  examined 
by  him,  but  often  only  as  the  result  of  examining  an  immense  number  of 
preparations.  The  absence  of  streptococci,  staphylococci,  and  pneumococci 
in  the  pus  makes  it  very  probable  that  the  case  is  tuberculous  even  if  the 
tubercle  bacillus  is  not  found.  A  more  certain  mode  of  determining 
whether  the  pus  is  tuberculous  or  not  is  by  inoculation  in  guinea-pigs. 
Out  of  thirteen  cases  of  tuberculous  empyema  observed  by  Netter,  in  twelve, 
inoculations  in  guinea-pigs  rendered  them  tuberculous,  and  out  of  six 
cases  Straus  succeeded  in  all. 

It  is  doubtful  whether  there  is  a  family  history  of  tubercle  in  as  large 
a  proportion  of  cases  of  tuberculous  pleurisy  as  in  cases  of  pulmonary 
tuberculosis.     Sittmann  noted  a  family  history  in  24  per  cent.,  which  is  a 


TUBERCULOSIS.  391 

lower  proportion  than  for  phthisis.  Every  one  who  sees  a  large  number 
of  cases  of  pulmonary  phthisis  must  have  been  struck  by  the  relative 
frequency  of  pleurisy  as  an  antecedent  in  these  cases. 

Osier  (Shattuck  Lecture)  has  given  a  very  useful  classification  of  the 
varieties  of  tuberculous  pleurisy. 

1.  Acute  tuberculous  pleurisy — (a)  Primary,  (b)  secondary  and  terminal, 
(c)  acute  tuberculous  suppurative  pleurisy. 

2.  Subacute  and  chronic — (a)  With  serofibrinous  effusion,  (h)  with 
purulent  exudation,  (c)  chronic  adhesive  tuberculous  pleurisy. 

In  the  ordinary  acute  form,  whether  primary  or  secondary,  the  condition 
appears  to  be  one  of  acute  miliary  tuberculosis  of  the  membrane  with  a 
serofibrinous  or  hemorrhagic  exudation.  The  amount  of  the  effused 
serum  may  be  very  large  or  never  more  than  a  few  ounces.  There  is 
nothing  characteristic  about  its  appearance.  It  has  already  been  pointed 
out  that  it  is  usually  sterile.  A  hemorrhagic  character  suggests  either 
tubercle  or  new  growth.  The  acute  cases  with  purulent  effusion  are 
decidedly  rare.  They  run  a  rapid  course.  The  pus  has  been  observed  to 
be  located  in  small  pockets  instead  of  forming  a  regular  empyema.  The 
membrane  is  frequently  lined  with  a  layer  of  fibrinous  lymph,  which  may 
be  of  considerable  thickness.  Such  cases  pass  into  the  chronic  form,  in 
which  the  pleura  becomes  greatly  thickened — the  thickening,  however, 
being  more  marked  in  the  case  of  the  parietal  pleura  than  in  that  of 
the  visceral  layer.  The  parietal  pleura  may  form  a  layer  two-fifths  of 
an  inch  thick,  or  even  more  in  the  case  of  the  diaphragmatic  layer.  The 
visceral  layer  is  only  a  third  or  half  as  thick.  Its  surface  is  sometimes 
smooth  and  greyish  white  in  colour,  and  sometimes  honeycombed  with  deep 
irregular  ulcers.  In  section  one  sees  either  with  the  naked  eye  or  under 
the  microscope  distinct  tubercles.  When  the  case  has  become  chronic,  the 
two  thickened  layers  of  the  pleura  may  be  generally  quite  adherent  and 
form  a  membrane  nearly  an  inch  thick,  made  up  of  fibrous  tissue  with 
perhaps  here  and  there  layers  of  caseous  material.  On  the  other  hand, 
adhesions  may  not  be  general,  but  fluid  may  be  collected  in  pockets  in 
various  situations.  Occasionally  the  fluid  in  one  pocket  may  be  serous, 
while  in  another  it  may  be  curdy  or  even  purulent.  The  effusion  in  the 
chronic  cases  may  be  either  serofibrinous  or  purulent.  The  serofibrinous 
effusion  may  be  very  large  in  amount,  and  frequently  re-accumulates  again 
and  again  after  tapping.  The  fluid  is  not  so  frequently  hemorrhagic  as  in 
the  acute  cases.  Tuberculous  empyema  is  essentially  very  chronic.  The 
effusion  is  never  absorbed  spontaneously,  and  very  rarely  makes  its  way 
into  a  bronchus  or  discharges  internally.  The  fluid  is  often  thinner  than 
ordinary  pus,  and  it  may  not  be  truly  purulent,  but  its  purulent  appearance 
may  be  due  to  the  presence  of  suspended  fatty  matter. 

Symptoms. — The  symptoms  and  physical  signs  of  tuberculous 
pleurisy  are  those  of  ordinary  pleurisy,  pain  in  the  side,  shortness 
of  breath,  and  fever,  together  with  friction  or  the  physical  signs  of 
effusion  There  is  no  means  of  distinguishing  the  one  from  the  other, 
apart  from  evidence  of  tubercle  elsewhere,  or  the  proof  of  the  tuber- 
culous nature  by  means  of  inoculation  or  otherwise  as  already  described. 
Tuberculous  cases,  however,  are  apt  to  become  chronic,  and  thus  fever 
becomes  persistent  or  effusion  recurs.  In  a  case  of  this  kind  under  my 
observation,  the  continuance  of  the  symptoms  suggested  the  existence  of  a 
loculated  empyema  which  was  explored  for  in  vain.  The  true  nature  of 
the  case  was  only  revealed  when  cerebral  symptoms  declared  themselves. 


392  GENERAL  DISEASES. 

The  patient  died  from  meningeal  tubercle.  In  the  case  of  tuberculous 
empyema  there  are  fewer  symptoms  and  less  disturbance  of  the  general 
health  than  in  ordinary  empyema.  The  effusion  may  be  extremely  large. 
The  same  remarks  apply  to  this  form  as  to  the  ordinary  serous  form. 

Diagnosis. — The  diagnosis  of  tuberculous  pleurisy  often  presents  great 
difficulty ;  but  it  must  be  remembered  that,  in  a  case  of  acute  idiopathic 
pleurisy,  tubercle  is  the  most  likely  cause.  Where  it  is  important  to  give  a 
positive  diagnosis,  the  inoculation  of  3  to  15  c.c.  of  the  serous  effusion  into 
the  peritoneum  of  a  guinea-pig  may  be  tried.  The  discovery  of  evidence 
of  tubercle  elsewhere  will  be  valuable.  After  recovery  from  an  attack  of 
pleurisy,  it  may  be  worth  while  to  test  the  patient  with  tuberculin.  In 
cases  with  purulent  effusion  the  tubercle  bacillus  may  possibly  be 
discovered.  Probably  the  most  frequent  mistakes  are  made  between 
ordinary  empyema,  especially  when  the  fluid  is  encysted,  and  tuberculous 
pleurisy.  The  only  way  to  avoid  missing  an  empyema  is  to  use  the 
exploring  needle  or  aspirator  whenever  there  is  a  suspicion  of  pus. 

Prognosis. — The  prognosis  of  primary  tuberculous  pleurisy  is  as 
regards  the  immediate  attack  decidedly  good.  This  is  shown  by  the  small 
number  of  deaths.  A  large  number,  however,  as  is  shown  by  the  statistics 
already  brought  forward,  develop  tubercle  elsewThere  sooner  or  later.  Where 
the  pleurisy  occurs  as  a  secondary  condition,  it  adds  to  the  gravity  of  the 
already  existing  disease;  but,  as  a  rule,  the  immediate  prognosis  is  not 
unfavourable.  Some  authorities  are  of  opinion  that  the  presence  of  an 
effusion  in  the  pleura  has  a  beneficial  influence  on  a  lung  affected  by 
tubercle.  The  prognosis  in  tuberculous  empyemata  is  naturally  not  so 
favourable  as  that  of  non-tuberculous.  The  former  often  become  chronic, 
and  terminate  fatally. 

Treatment. — The  treatment  of  tuberculous  pleurisy  embraces  all  those 
measures  which  have  been  found  to  be  useful  in  the  ordinary  disease.  In 
the  early  stages  where  there  is  pain,  rest  and  fixation  of  the  side  by  bella- 
donna strapping  give  relief.  Aspiration  may  have  to  be  frequently  repeated 
when  the  disease  becomes  chronic.  Counter-irritation  by  means  of  iodine 
or  by  blistering  is  sometimes  useful  in  promoting  the  absorption  of  the 
fluid.  Graduated  exercises  may  help  to  bring  about  the  re-expansion  of 
the  lung.  After  recovery  from  an  attack  of  pleurisy,  it  is  of  the  highest 
importance  that  the  general  health  should  be  re-established,  and,  where  it 
is  possible,  the  patient  should  spend  one  or  even  two  winters  abroad,  or,  if 
a  good  sailor,  he  might  take  a  long  sea  voyage  with  advantage. 

Pericardium. 

Tuberculous  pericarditis  is  decidedly  rarer  than  similar  affections  of  the 
pleura  and  peritoneum. 

Etiology. — It  is  much  more  frequently  secondary  than  primary.  It 
is  usually  associated  with,  and  secondary  to,  tuberculosis  of  the  bronchial  and 
anterior  mediastinal  glands.  In  a  considerable  proportion  of  cases,  tubercle 
of  the  peritoneum,  pleura,  or  lungs  is  also  present.  It  may  occur  at  any  age, 
and  cases  have  been  noted  in  infants  under  a  year,  as  well  as  in  old  people. 
Virchow  recorded  a  primary  case  in  a  man  of  81,  in  whom,  moreover,  this 
was  the  only  lesion.  It  appears  to  be  more  frequent  in  males  than  in 
females.  The  following  particulars  may  help  to  indicate  the  relative 
frequency  of  its  occurrence. 

Dietrich  and  Frerichs  found  tubercle  of  the  pericardium  in  nine  out  of 


TUBERCULOSIS. 


393 


578  cases  of  tuberculosis.  Osier,  out  of  275  cases  with  tuberculous  lesions 
at  the  Montreal  Hospital,  noted  seven  in  which  the  pericardium  was 
involved.  Wilson  Fox  found  it  once  in  ninety-three  cases  of  phthisis. 
Out  of  645  cases  of  pulmonary  tuberculosis  at  the  Brompton  Hospital, 
there  were  fourteen  in  which  adherent  pericardium  was  found,  and  there 
were  fourteen  in  which  there  was  recent  pericarditis.  In  about  half  of 
the  latter  cases,  which  were  examined  microscopically,  tubercle  was 
found.  Lebert  states  that  tubercle  exists  in  20  to  25  per  cent,  of  all 
cases  of  pericarditis,  while  Bamberger  makes  the  proportion  14  per  cent. 

Morbid  anatomy. — It  is  not  uncommon  in  general  miliary  tuber- 
culosis to  find  miliary  tubercles  present  on  both  layers  of  the  pericardium, 
but  as  a  rule  they  are  not  numerous.  When  pericarditis  occurs,  the  develop- 
ment of  grey  miliary  tubercles  in  the  pericardial  membrane  is  accom- 
panied by  an  injection  of  the  vessels  in  their  neighbourhood,  with  which 
may  be  associated  small  haemorrhages.  Subsequently  there  is  a  deposit  of 
fibrinous  lymph  on  the  surface  of  the  membrane,  embedding  and  obscuring 
the  tubercles.  This  may  be  preceded  or  followed  by  an  effusion  into  the 
pericardial  sac,  generally  a  somewhat  turbid  serum,  in  which  are  suspended 
flakes  of  lymph.  The  effusion  may  be  blood-stained  or  purulent,  but  the 
latter  is  decidedly  rare.  The  amount  of  effusion  may  be  very  large,  and 
the  pericardial  sac  greatly  distended.  Musser  has  recorded  a  case  where 
at  the  post-mortem  the  sac  contained  64  oz.  of  bloody  serum,  while  37  oz. 
of  similar  fluid  were  removed  by  aspiration  during  life.  Most  commonly 
the  amount  of  fluid  is  small  and  becomes  absorbed,  while  adhesions  form 
between  the  two  layers  of  the  pericardium,  the  sac  of  which  is  gradually 
obliterated  in  whole  or  in  part.  The  parietal  layer  in  the  recent  stage  is 
generally  considerably  thickened  and  cedematous.  In  a  case  of  old  standing, 
or  even  in  a  recent  case  where  there  is  much  deposit  of  fibrinous  lymph, 
it  may  be  very  difficult  or  even  impossible  to  recognise  the  presence  of 
tubercles  with  the  naked  eye.  It  is  only  by  cutting  sections  and  examin- 
ing microscopically,  that  the  true  nature  of  such  cases  can  be  determined. 
In  old  cases  both  layers  of  the  pericardium  are  thickened,  sometimes  very 
much  so. 

Symptoms. — The  symptoms  and  physical  signs  of  tuberculous  peri- 
carditis do  not  differ  essentially  from  those  of  the  ordinary  affection.  In  many 
cases  the  malady  remains  latent  and  is  only  discovered  accidentally  at  the 
post-mortem.  In  other  cases  the  usual  acute  symptoms  of  pericarditis  are 
present.  In  the  chronic  adhesive  cases,  the  symptoms,  when  such  exist, 
are  those  of  chronic  congestion  of  the  lungs,  liver,  etc.  The  physical  signs 
are  numerous,  and,  as  a  rule,  not  conclusive  as  to  the  nature  of  the  affection. 

Diagnosis. — The  tuberculous  nature  of  pericarditis  is  always  probable 
when  it  occurs  in  a  tuberculous  subject  in  whom  other  causes,  such  as 
rheumatism  and  renal  disease,  are  unlikely.  Apart  from  the  evidence  of 
tubercle  in  other  organs,  and  the  absence  of  other  causes  of  pericarditis, 
there  is  little  to  help  us  in  arriving  at  a  diagnosis.  An  unusually  protracted 
course  and  an  irregularly  febrile  temperature  are  in  favour  of  tubercle.  If 
paracentesis  is  performed,  the  presence  of  blood  in  the  exudation  favours 
tubercle.  An  examination  of  the  exudation  for  bacilli  or  inoculation  ex- 
periments in  animals  may  sometimes  afford  conclusive  evidence  as  to  the 
nature  of  the  case. 

Prognosis  and  treatment. — The  prognosis  when  a  case  of  peri- 
carditis can  be  diagnosed  as  tuberculous  is  certainly  unfavourable.  There 
is  no  reason  why,  when  the  tubercle  is  limited  to  the  pericardium,  recovery 


394  GENERAL  DISEASES. 

should  not  frequently  take  place.  These,  however,  are  just  the  cases  in 
which  diagnosis  fails.  Tuberculous  pericarditis  calls  for  no  special  treat- 
ment other  than  would  be  adopted  in  the  ordinary  disease.  Osier  speaks 
highly  of  the  continuous  application  of  the  ice-bag  or  Leiter's  coils  as 
allaying  pain  and  checking  the  tendency  to  effusion. 

Peritoneum. 

Etiology. — Tuberculous  peritonitis  is  frequently  associated  with  the 
presence  of  tubercle  in  other  parts,  especially  in  the  pleura.  Tuberculosis 
of  pleura  coexisted  in  seventy-five  out  of  167  cases  of  tuberculous  peri- 
tonitis collected  by  Osier.  The  disease  is  frequently  primary  in  the 
peritoneum,  but  how  the  virus  reaches  it  is  not  clear.  It  is  not  un- 
commonly secondary  to  pulmonary  tuberculosis.  Thus  it  was  found  hi 
fifteen  out  of  382  cases  of  pulmonary  tuberculosis  examined  post-mortem 
at  the  Brompton  Hospital.  It  is  common  in  children,  but  may  occur  at  any 
age  of  life.  Statistics,  however,  are  useless  to  illustrate  the  age  distribution. 
Thus,  out  of  100  cases  collected  by  Hawkins  at  St.  Thomas's  Hospital,  forty- 
three  occurred  in  children  under  10 ;  while  out  of  357  collected  by  Osier, 
only  twenty-seven  were  in  children  under  10.  It  is  a  disputed  point 
whether  it  is  more  common  in  males  or  females.  Fagge  found  the  disease 
more  than  twice  as  common  in  men  as  in  women.  Osier  says  it  is 
certainly  more  common  among  females.  The  statistics  of  surgeons  show 
the  disease  to  be  more  common  among  females ;  those  of  the  post-mortem 
room  show  it  to  be  more  common  among  males. 

A  considerable  number  of  cases  have  been  observed  where  tuberculous 
peritonitis  coexisted  with  cirrhosis  of  the  liver.  As  I  have  pointed  out, 
alcoholic  subjects  appear  to  be  more  liable  to  tubercle  than  those  who 
are  temperate. 

The  association  of  tuberculous  peritonitis  with  similar  disease  of  the 
Fallopian  tubes  deserves  to  be  specially  mentioned.  The  latter  are  found 
to  be  affected  in  from  30  to  50  per  cent,  of  the  fatal  cases  in  women.  It  is 
difficult  in  these  cases  to  decide  in  which  part  the  disease  has  originated. 
Although  the  fimbriated  extremity  of  the  tube  is  in  many  instances  the 
most  markedly  diseased,  this  does  not  prove  that  infection  has  come  vid 
the  peritoneum,  for,  as  has  been  pointed  out  by  Whitridge  Williams, 
this  portion  is  much  more  vascular  than  the  rest,  and  therefore  the  most 
likely  to  be  affected  by  blood  infection. 

Morbid  anatomy. — It  is  not  at  all  unusual,  in  association  with 
tuberculous  ulcers  of  the  intestines,  to  see  a  deposit  of  grey  translucent 
granulations  on  the  peritoneal  surface  in  the  neighbourhood  of  the  ulcers. 
Sometimes,  on  the  peritoneal  aspect  of  the  ulcers,  there  is  a  local  deposit 
of  fibrinous  lymph.  It  is  seldom,  however,  that  there  is  a  general 
tuberculous  infection  of  the  peritoneum. 

Sometimes,  as  a  part  of  general  miliary  tuberculosis,  there  is  a 
distribution  of  small  miliary  tubercles  on  the  surface  of  the  peritoneum, 
most  abundant  on  the  parietal  layer.  When  tuberculous  peritonitis 
occurs,  grey  miliary  tubercles  appear  over  a  wide  area  of  the  serous 
membrane,  but  especially  on  the  under  surface  of  the  diaphragm  and 
on  the  parietal  peritoneum  in  the  flanks.  These  may  attain  the  size 
of  a  hemp  seed,  and  may  be  associated  with  larger  yellow  caseating 
nodules.  In  more  severe  cases  the  granulations  appear  in  the  deeper 
connective  tissue  in  the  mesentery  and  great  omentum.     In  addition,  a 


TUBERCULOSIS.  395 

number  of  caseous  masses,  due  to  the  coalescence  of  smaller  tubercles, 
may  be  met  with.  There  is  generally  an  effusion  of  fluid  into  the  peritoneal 
cavity,  sometimes  large  in  amount.  The  fluid  is  at  first  clear  yellow  serum, 
but  may  contain  fibrinous  floccules. 

When  the  tubercles  are  numerous,  the  membrane  becomes  covered  with 
a  layer  of  fibrinous  lymph,  and  the  coils  of  intestine  are  apt  to  become 
adherent  to  one  another  and  to  the  abdominal  wall.  In  some  cases  a 
general  obliteration  of  the  cavity  may  take  place.  The  effused  fluid  often 
undergoes  absorption  in  whole  or  in  part  at  a  later  stage,  or  it  may  become 
purif orm.  As  the  result  of  adhesions,  it  is  apt  to  become  encysted,  especially 
in  the  dependent  parts.     At  a  later  period  the  pus  may  dry  up. 

The  great  omentum  is  frequently  the  seat  of  a  deposit  of  caseous  tubercle. 
It  then  becomes  thickened,  contracted,  adherent  to  the  intestine  and 
abdominal  wall,  and  may  form,  as  already  mentioned,  a  transverse  bar- 
like tumour  lying  across  the  abdomen  about  the  level  of  the  umbilicus. 
The  mesentery  may  also  be  the  seat  of  similar  changes,  so  that  it 
becomes  thickened  and  contracted,  and  the  small  intestines  are  massed 
together  about  the  middle  of  the  abdomen. 

At  the  post-mortem  it  is  often  extremely  difficult  to  obtain  a  correct 
idea  of  the  true  state  of  affairs.  The  intestines  are  bound  together  in  all 
directions,  and  firmly  glued  to  the  abdominal  wall,  the  great  omentum,  and 
the  various  organs.  The  only  feasible  method  of  examining  the  case  is  to 
cut  sections  in  various  directions.  In  making  these  sections,  one  comes  on 
collections  of  pus  or  serum  or  caseous  deposits.  Sometimes  it  is  found 
that  the  intestines  have  been  perforated  in  various  situations,  and  that,  as 
a  result,  fsecal  abscesses  have  formed. 

Symptoms. — Tuberculous  peritonitis  sometimes  manifests  no  decided 
symptoms,  and  symptoms  when  present  may  not  only  be  vague  but  also 
misleading.  When  it  occurs  in  the  course  of  pulmonary  tuberculosis,  there 
may  be  little  or  nothing  to  attract  attention  to  the  abdominal  condition. 
In  many  of  the  cases  which  have  been  treated  by  laparotomy,  apart  from 
the  existence  of  a  tumour  or  evidence  of  disease  of  the  pelvic  organs,  there 
has  been  no  indication  of  the  nature  of  the  disease.  This  variety  may  be 
spoken  of  as  the  latent  form  of  the  disease.  Besides  this  there  are  two 
main  forms — an  acute  and  a  chronic  variety. 

The  acute  form  has  been  already  described  as  the  abdominal  form 
of  acute  miliary  tuberculosis. 

In  the  chronic  form,  the  symptoms,  while  similar  to  those  met  with 
in  the  acute  form,  are  of  less  severity  and  of  longer  duration. 

It  must  be  clearly  borne  in  mind  that  the  acute  may  pass  into  the 
chronic  form.  The  temperature  is  variable.  There  may  be  some  pyrexia 
such  as  exists  in  the  acute  cases,  but  more  commonly  the  temperature 
varies  little  from  normal,  or  it  may  be  persistently  subnormal.  Frequently 
the  most  marked  feature  of  chronic  cases  is  the  presence  of  a  tumour, 
which  may  lead  to  erroneous  diagnosis  of  ovarian  tumour  or  malignant 
disease. 

The  most  common  tumour  is  a  transverse  bar-like  mass  situated 
at  or  slightly  above  the  level  of  the  umbilicus,  formed  by  the  thickened, 
infiltrated,  and  rounded  great  omentum.  This  mass  may  be  mistaken  for 
the  lower  border  of  an  enlarged  liver,  but  can  usually  be  distinguished  from 
it  by  observing  the  presence  of  resonance  above  it. 

In  some  cases  there  are  sacculated  collections  of  fluid  lying  in 
pockets  formed  by   adherent  coils   of   intestine,  the  abdominal  wall,  the 


396  GENERAL  DISEASES. 

mesentery,  and  the  pelvic  or  other  organs.  Such  tumours  may  be  altogether 
fluid,  or  they  may  contain  caseous  masses  embedded  among  the  parietal 
adhesions,  giving  them  a  nodular  character.  These  tumours,  due  to 
encysted  fluid,  have  been  specially  studied  by  Osier,  who  has  subdivided 
them.  Eirst,  those  in  the  upper  region  of  the  abdomen,  which  are  most 
commonly  met  with  in  connection  with  perihepatitis.  Second,  those 
in  the  middle  region — those  in  which  the  entire  anterior  portion  of  the 
peritoneal  cavity  is  occupied  by  a  single  collection  of  fluid ;  and  those  in 
which  there  is  a  more  limited  sacculated  exudation  on  one  or  other  side 
of  the  abdomen  or  in  the  middle  line.  Third,  sacculated  collections  in 
the  pelvic  region,  in  the  case  of  females,  which  are  nearly  always  con- 
nected with  disease  of  the  Fallopian  tubes.  It  is  these  tumours  that  are 
so  frequently  mistaken  for  ovarian  disease,  and  many  laparotomies  have 
been  performed  under  this  impression. 

Thickened  and  retracted  intestinal  coils  sometimes  form  a  tumour 
of  great  distinctness.  Such  a  formation  is  most  common  in  the  caecal 
region.  Enlarged  mesenteric  glands  give  rise  to  a  lumpy  feeling  of  the 
abdomen.     This  is  more  common  in  children  than  in  adults. 

Although  such  tumours  are  a  common  feature  of  chronic  tuberculous 
peritonitis,  they  are  not  always  met  with.  When  there  is  no  tumour,  the 
abdomen  is  generally  large  and  doughy.  Ascites  usually  exists  at  some 
period,  but  not  to  a  marked  degree.  A  considerable  proportion  of  the 
chronic  cases  get  well. 

Diagnosis. — The  acute  form. — These  cases  are  often  at  first  mistaken 
for  enteric  fever,  which  is  not  excluded  by  absence  of  spots  and  of  enlarge- 
ment of  spleen.  Evidence  of  tuberculous  disease  elsewhere  will  make 
tuberculous  peritonitis  more  probable.  The  character  of  the  temperature, 
which  wants  the  regularity  of  enteric  fever,  may  help.  It  is  sometimes 
only  after  the  disease  has  lasted  an  unusual  time  for  enteric  fever,  that 
its  true  nature  is  suspected.  Serum  diagnosis  should  be  employed  in  all 
doubtful  cases. 

In  the  chronica  form,  the  principal  difficulty  is  in  excluding  ovarian 
tumour  and  malignant  growth.  As  regards  ovarian  tumour,  the  most 
important  points  are  the  normal  temperature  and  the  absence  of  disturb- 
ances of  the  digestive  organs,  and  of  signs  of  disease  in  the  tubes,  lungs,  or 
elsewhere.  The  tumour  itself  is  usually  not  so  well  defined  as  an  ovarian, 
but  in  exceptional  cases  no  difference  can  be  made  out.  When  malignant 
disease  exists,  there  is  usually  more  emaciation,  a  greater  degree  of  cachexia, 
and  greater  constitutional  disturbance.  Cases  of  chronic  tuberculous 
peritonitis  with  a  considerable  amount  of  ascites  are  sometimes  mistaken 
for  ascites  connected  with  cirrhosis  of  the  liver.  The  difficulty  is  all  the 
greater,  inasmuch  as  the  two  are  sometimes  associated,  and  tuberculous 
peritonitis  may  be  met  with  in  intemperate  subjects.  In  such  cases  the 
association  of  unilateral  pleural  effusion,  the  course  of  the  temperature,  etc., 
may  help. 

Prognosis. — It  is  now  recognised  that  a  considerable  proportion  of 
cases  of  tuberculous  peritonitis  recover.  Of  100  cases  treated  at  St.  Thomas's 
Hospital,  Hawkins  records  that  forty  proved  fatal,  while  at  least  twenty-one 
made  good  recoveries,  remaining  well  for  from  nine  months  to  nine  years. 
The  prognosis  is  better  between  the  ages  of  5  and  10  than  at  any  other 
period.  In  patients  over  20  years  of  age  quite  a  large  proportion  prove 
fatal.  The  presence  of  extensive  disease  of  lung,  a  history  of  alcoholism, 
the  coexistence  of  tuberculous  disease  of  the  pleura,  pericardium,  uterine 


TUBERCULOSIS.  397 

appendages,  etc.,  are  all  unfavourable  points.  Cases  where  there  are 
sacculated  collections  of  pus  are  especially  unfavourable.  When  the 
disease  is  discovered  unexpectedly  during  a  laparotomy,  the  prognosis  is 
favourable. 

Treatment. — The  treatment  of  tuberculous  peritonitis  divides  itself 
into  hygienic,  medicinal,  and  operative.  The  first  two  methods  should  always 
have  a  fair  trial.  The  patient  should  be  kept  at  rest,  but  as  far  as  possible 
should  lead  an  open-air  life.  Bracing  sea  air,  such  as  that  of  Margate, 
Cromer,  or  North  Berwick,  is  specially  useful.  Plain,  wholesome,  and 
nutritious  food  should  be  given,  such  as  is  adapted  to  the  state  of  the 
bowels,  being  laxative  when  there  is  constipation,  and  vice  versd.  The 
appetite  and  digestion  may  be  improved  by  the  administration  of  a  simple 
alkaline  tonic.  Where  there  is  diarrhoea,  bismuth  is  very  valuable.  The 
subnitrate,  the  subgallate,  or  the  salicylate,  in  doses  of  5  to  20  grs.,  may  be 
given  with  or  without  opium,  the  dose  being  adapted  to  the  age  of  the 
patient.  Cod-liver  oil,  when  well  borne,  is  very  valuable,  but  care  should 
be  exercised  not  to  spoil  the  appetite  and  digestion  by  too  large  a  dose,  or 
by  giving  it  at  all  where  it  excites  nausea.  The  remarks  under  the  head 
of  Treatment  of  Pulmonary  Tuberculosis  apply  with  special  force  here. 
Pancreatic  emulsion  and  petroleum  emulsion  are  also  useful.  The  syrup 
of  phosphate  of  iron  or  iodide  of  iron  may  prove  beneficial  in  doses  of  20 
minims  to  1  drm.  French  authorities  speak  highly  of  the  strop  iodotannique, 
a  combination  of  iodine  and  tannin. 

Local  applications  to  the  abdomen  have  been  found  valuable.  Thus 
Fagge  speaks  very  highly  of  linimentum  hydrargyri  spread  on  flannel  and 
kept  continuously  closely  applied  to  the  abdomen.  Various  liniments, 
such  as  the  linimentum  ammonise,  or  lin.  tereb.  acet.,  may  be  gently 
applied  with  rubbing.  Probably  the  massage  is  of  benefit  independently 
of  the  application.  Marfan  recommends  painting  the  abdomen  with 
tincture  of  iodine,  followed  by  a  coating  of  flexible  collodium,  the  applica- 
tion to  be  renewed  weekly  or  once  a  fortnight.  This,  he  says,  immobilises 
the  abdominal  wall,  keeps  the  organs  at  rest,  and  diminishes  hypersemia. 

In  cases  where  no  improvement  results,  after  four  to  six  weeks  in 
acute  cases,  and  after  four  to  six  months  in  chronic  cases,  laparotomy  may 
be  resorted  to.  The  increase  or  continuance  of  ascites  and  pyrexial 
temperature  are  the  chief  indications  for  this  measure.  A  free  incision 
should  be  made,  and  the  fluid  thoroughly  evacuated.  If  the  fluid  is  serous, 
the  wound  is  at  once  closed.  When  the  fluid  is  purulent,  a  drainage  tube 
must  be  left  in  for  a  short  time. 

How  laparotomy  acts  in  these  cases  is  not  satisfactorily  explained,  but 
the  results,  on  the  whole,  have  been  good.  It  came  into  vogue  on  account 
of  the  good  results  which  followed  the  operation  at  the  hands  of  Spencer, 
Wells,  and  Konig.  The  earliest  cases  were  done  for  purposes  of  explora- 
tion, and  tubercle  being  found,  no  improvement  was  expected.  It  proved 
quite  otherwise,  and  the  operation  has  since  been  frequently  performed 
with  equally  successful  results. 

Nannoti  and  Baciochi  induced  tuberculous  peritonitis  in  dogs  and 
rabbits.  A  certain  number  were  subjected  to  laparotomy,  and  the  re- 
mainder left  to  themselves.  The  results  in  the  case  of  the  dogs  were 
the  more  striking.  Of  those  which  underwent  laparotomy,  seven  recovered 
and  two  were  not  benefited.  Of  those  left  to  themselves,  only  one  re- 
covered. From  the  changes  found  in  the  animals  which  recovered,  the 
authors  infer  "  that  the  operative  interference  stimulates  or  increases  the 


398  GENERAL  DISEASES. 

reparative  changes  by  the   mechanical  influence  which  it  exerts  on  the 
impressionable  peritoneum." 

Multiple  Serous  Tubeecle. 

Although  we  have  given  separate  descriptions  of  tuberculous  pleurisy, 
peritonitis,  and  pericarditis,  it  must  be  borne  in  mind  that  these  affections 
are  frequently  combined.  This,  it  has  already  been  pointed  out,  is  especi- 
ally likely  when  the  peritoneum  is  one  of  the  membranes  involved. 

TUBEBCULOSIS  OF  THE  EESPIEATOEY  SYSTEM. 

Nose. 

Tuberculosis  of  the  nasal  membrane  is  rare.  Considering  the  frequency 
with  which  the  tubercle  bacillus  is  found  in  the  nasal  cavities,  the  rarity 
of  the  disease  shows  how  great  must  be  the  resisting  power  of  the  mucous 
membrane.  It  is  sometimes  primary,  but  more  commonly  is  secondary  to 
pulmonary  and  laryngeal  tuberculosis.  It  shows  itself  either  under  the 
form  of  ulceration .  or  tumour  or  both.  Tumour  is  usually  met  with  in 
primary  cases,  ulceration  in  secondary.  The  seat  of  ulceration  is  prefer- 
ably the  septum  cartilagineum,  of  tumour  the  turbinated  bones.  It 
occurs  at  any  age,  but  most  frequently  between  10  and  40.  It  is  equally 
prevalent  in  the  two  sexes.  The  ulcers  are  generally  shallow  and  sur- 
rounded by  elevated  soft  margins  showing  miliary  tubercles.  The  tumours 
are  rounded  or  elliptical,  with  a  granular  surface,  greyish  or  greyish  yellow, 
of  soft  consistence  and  easily  made  to  bleed.  The  disease  may  by  ex- 
tension involve  the  naso-lachrymal  duct  and  the  conjunctiva. 

Symptoms  may  be  purely  negative.  Pain  is  rarely  present.  In 
the  ulcerative  variety,  there  may  be  profuse  muco-purulent  discharge, 
which  is  often  foetid  and  sometimes  mixed  with  blood.  On  examina- 
tion with  the  nasal  speculum,  the  affected  side  of  the  nose  is  probably 
found  to  be  filled  with  crusts,  on  removal  of  which  the  characteristic 
ulcers  will  be  seen.  Tumour  will  probably  produce  obstruction  to  the 
breathing. 

Diagnosis,  prognosis,  and  treatment. — Syphilis  and  new 
growth  may  be  difficult  to  eliminate.  In  secondary  cases,  evidence  of 
tuberculosis  elsewhere  will  help.  In  primary  cases,  it  may  be  impossible 
to  decide  the  nature  of  the  disease  without  microscopic  examination  of 
a  portion  of  the  growth  or  the  discovery  of  the  bacillus  in  the  scrapings. 
The  course  of  the  disease  is  very  chronic.  It  is  apt  to  relapse  when 
surgically  dealt  with.  It  is  not  in  itself  dangerous  to  life,  but  may 
be  complicated  with  meningitis,  etc.  Constitutional  remedies  should 
always  be  employed  New  growths  should  be  removed  as  thoroughly 
as  possible.  Ulcers  should  be  scraped  and  treated  with  lactic  acid  or 
cauterised,  the  same  precautions  being  taken  as  in  the  case  of  laryngeal 
tuberculosis.  Cleansing  and  disinfection  of  the  nasal  cavity  is  always 
important. 

Larynx. 

Etiology  and  morbid  anatomy.  —  Laryngeal  tuberculosis  is 
rarely  primary.  As  commonly  met  with  in  practice,  it  is  secondary  to 
pulmonary  phthisis,  in  the  course  of  which  it  is  usually  a  late  phenomenon. 


TUBERCULOSIS.  399 

Its  frequency  is  shown  by  the  following  statistics.  It  was  met  with  in  472 
cases  out  of  1008  autopsies  at  the  Brompton  Hospital.  This  gives  the 
large  proportion  of  46 -8  per  cent.  This  is  a  considerably  higher  percentage 
than  that  given  by  Heinze,  who  met  with  376  cases  of  laryngeal  ulceration 
among  1226  cases  of  pulmonary  phthisis,  giving  30*6  per  cent. ;  but  Heinze 
thinks  his  estimate  is  too  low,  for  in  184  cases  where  the  larynx  was 
specially  examined,  it  was  found  to  be  affected  in  38  per  cent.  Frerichs  in 
250  cases  of  chronic  phthisis  found  the  larynx  affected  in  101,  or  in  40*4 
per  cent.  Ivall  in  1000  post-mortems  found  the  larynx  affected  in  239. 
Males  are  not  only  actually  but  relatively  more  frequently  the  subjects  of 
laryngeal  tuberculosis  than  females.  Thus  the  males  affected  with 
laryngeal  tuberculosis  were  three  times  as  numerous  as  the  females  at  the 
Brompton  Hospital,  while  during  the  same  period  the  males  affected  with 
pulmonary  phthisis  were  only  twice  as  numerous  as  the  females.  The 
percentage  for  males  was  51*7,  and  for  females  36*7.  Heinze  found  a 
corresponding  disproportion,  33*6  per  cent,  of  the  males  had  the  larynx 
affected,  as  against  21  "6  of  the  females. 

The  greater  liability  of  the  male  sex  to  disease  of  the  larynx  is  not 
peculiar  to  tuberculosis,  but  is  found  to  exist  for  most  laryngeal  affections. 
Thus  men  suffer  much  more  frequently  than  women  from  chronic  laryn- 
gitis and  from  laryngeal  growths.  Males,  through  their  occupations,  are 
more  exposed  to  dust  and  to  extremes  of  hot  and  cold  air,  and  this  may 
partly  account  for  the  disproportion.  The  possible  influence  of  smoking 
must  also  be  considered.  The  mode  of  infection  in  most  cases  is  un- 
doubtedly from  the  lungs  by  means  of  the  bacilli-laden  sputum,  but 
primary  cases  in  which  the  bacillus  is  probably  directly  conveyed  to  the 
larynx  through  inhalation,  are  more  common  than  is  usually  taught.  It 
is  evident  that  the  larynx  must  exhibit  a  considerable  degree  of  resistance, 
as  shown  by  the  long  period  in  which  it  remains  unaffected  in  pulmonary 
phthisis,  although  the  bacillus  must  be  constantly  passing  over  its  mucous 
membrane.  Lake  suggests  that  the  first  part  of  the  process  is  a  surface 
infection  by  the  micrococci  of  the  sputum,  which  cause  a  minute  abscess 
in  the  epithelial  layer  tending  to  the  formation  of  a  shallow  ulcer,  which 
subsequently  becomes  infected  by  the  bacilli.  We  know,  however,  that 
the  bacilli  have  the  power  of  penetrating  the  mucous  membranes  without 
any  breach  of  surface,  and  that  an  erosion  is  not  a  necessary  preliminary 
condition. 

It  is  certain  that  tuberculous  nodules  are  found  in  the  mucous 
membrane  previous  to  the  existence  of  any  apparent  erosion.  The  tubercles 
are  generally  at  first  situated  in  the  superficial  layers  of  the  mucosa 
just  beneath  the  epithelium,  and  gradually  occupy  the  deeper  layers, 
although  always  less  abundant  there.  These  become  caseous,  the  epithelium 
over  them  becomes  necrotic,  and  an  ulcer  is  formed,  which  gradually 
increases  in  depth  and  extent.  The  tissue  in  which  the  tubercles  are 
deposited  becomes  generally  thickened,  so  that  the  depth  of  the  mucous 
membrane  is  three  or  four  times  as  great  as  the  normal. 

The  most  common  seats  of  tuberculous  ulceration  are  the  vocal  cords, 
especially  their  posterior  extremities  the  'processus  vocales,  and  the  inter- 
arytenoid  fold.  The  aryepiglottic  folds  frequently  become  swollen.  The 
epiglottis  is  less  frequently  affected,  and  the  ventricular  bands  rarely.  We 
shall  consider  the  various  lesions  separately.  As  regards  the  cords,  a 
shallow  superficial  ulcer  appears  on  the  posterior  third  of  the  cord,  most 
usually  on  its  upper  surface,  sometimes  on  the  internal  edge.     This  ulcer 


400  GENERAL  DISEASES. 

may  spread  in  depth  until  the  cartilage  is  reached,  but  often  may  also 
spread  longitudinally,  a  not  uncommon  result  being  a  splitting  of  the 
cord,  producing  a  terrace-like  arrangement.  Sometimes  only  one  cord  is 
affected,  at  other  times  both.  Sometimes  there  is  a  fleshy  swelling  of  the 
whole  of  one  cord.  In  the  inter-arytenoid  fold  first  there  is  swelling, 
which  produces  a  projection  between  the  cords,  and  next  ulceration  occurs, 
producing  a  jagged  appearance  from  the  presence  of  protruding  granula- 
tions. Such  inter-arytenoid  ulceration  is  very  characteristic.  When  the 
arytenoids  are  affected,  there  is  more  or  less  swelling,  so  that  these  often 
form  large  pyriform  bodies.  The  epiglottis  may  be  uniformly  swollen, 
forming  a  turban-shaped  mass.  When  ulceration  occurs,  this,  as  a  rule, 
first  appears  on  the  laryngeal  aspect.  Much  destruction  of  the  epiglottis 
is  more  usual  in  syphilis  than  in  tuberculosis,  although  more  common  in 
tubercle  than  is  generally  supposed.  The  ventricular  bands  may  be  con- 
siderably swollen  and  ulcerated,  but  this  usually  occurs  late,  when  there  is 
extensive  general  disease. 

A  few  cases  have  been  recorded  where  the  tuberculous  process  has 
resulted  in  the  formation  of  a  definite  tumour.  Such  tumours  are  usually 
sessile,  and  situated  on  the  cords,  ventricular  bands  or  ventricles,  but  may 
occur  on  any  part.  They  are  of  slow  growth,  and  have  been  known  to 
last  for  years.  They  consist  of  round-celled  tissue,  enclosing  tubercles, 
sometimes  with  giant  cells  and  sometimes  caseous  and  degenerate. 
Tubercle  bacilli  are  generally  to  be  detected  in  them. 

Symptoms. — The  symptoms  of  laryngeal  tuberculosis  are  altera- 
tions of  the  voice,  pain,  difficulty  in  swallowing,  cough,  dyspnoea,  etc. 
Hoarseness  or  aphonia  is  generally  the  earliest  of  these  to  be  noticed. 
Hoarseness  is  the  more  common  of  the  two,  but  aphonia  comes  on  sooner 
or  later.  Abnormal  sensations  in  the  throat  are  not  infrequently  notice- 
able early.  These  may  be  classed  under  the  name  paresthesia,  and  consist 
of  slight  soreness,  pricking,  and  various  degrees  of  discomfort  about  the 
larynx.  Actual  pain  does  not  generally  occur  until  there  is  ulceration, 
and  it  is  specially  marked  when  the  epiglottis  and  aryepiglottic  folds  have 
become  affected.  Under  the  same  circumstances,  dysphagia  is  usually 
experienced.  This  may  simply  amount  to  a  certain  degree  of  difficulty  in 
swallowing,  but  generally  there  is  pain  on  swallowing,  as  well  as  difficulty 
when  ulceration  has  occurred  in  the  situations  mentioned.  Dysphagia  is 
always  a  grave  symptom.  Still  more  serious  is  the  entrance  of  food  into 
the  trachea  on  swallowing.  Actual  dyspnoea  is  rare,  but  when  it  occurs  is 
exceedingly  grave,  and  points  to  the  existence  of  stenosis  of  the  glottis. 
Cough  is  frequent,  but  is  not  specially  characteristic. 

The  laryngoscopic  appearances  will  be  gathered  from  the  description 
already  given  of  the  morbid  anatomy.  A  good  deal  of  stress  has  been 
laid  on  the  existence  of  marked  anemia  of  the  larynx  in  the  early  stages. 
It  often  happens,  however,  that  there  is  some  congestion  just  at  this  time. 
When  the  vocal  cords  are  affected,  they  are  at  first  usually  reddened  and 
slightly  swollen,  and  an  ulcer  is  probably  visible  at  the  processus  vocalis. 
When  the  disease  is  more  advanced,  the  split  or  terraced  appearance  of 
the  cords  is  very  characteristic.  A  considerable  portion  of  the  cords  may 
be  destroyed.  Ulceration  in  the  inter-arytenoid  fold,  with  the  projecting 
granulations  as  already  described,  is  another  early  affection.  The  pyriform 
swellings  of  the  aryepiglottic  folds  and  the  turban-like  swelling  of  the 
epiglottis  are  very  characteristic  of  the  later  stages.  It  is  not  uncommon 
in  the  course  of  the  disease  to  get  impaired  mobility  of  the  vocal  cords. 


TUBERCULOSIS.  401 

Functional  paresis  of  the  adductors  is  frequent  at  an  early  stage.  A  cord 
may  become  completely  fixed  from  ankylosis  of  the  corresponding  crico- 
arytenoid joint,  or  it  may  become  more  or  less  motionless  from  involve- 
ment of  the  recurrent  laryngeal. 

Diagnosis. — Chronic  laryngitis,  syphilis,  and  malignant  disease  have 
to  be  carefully  considered.  Tuberculous  laryngitis  is  sometimes  taken  for 
chronic  laryngitis,  especially  in  the  early  stages.  The  rule  laid  down  by 
Morell  Mackenzie,  that  in  all  cases  of  chronic  laryngitis  of  some  months' 
standing  the  lungs  should  be  carefully  examined,  is  an  excellent  one.  The 
examination  of  the  sputum  in  such  a  case  is  also  of  great  importance. 
Limitation  of  chronic  laryngitis  to  one  cord  is  always  suspicious  of 
tuberculosis.  I  have  seen  a  number  of  cases  where  it  would  have  been 
impossible  to  have  given  a  positive  diagnosis  without  the  aid  afforded  by 
the  discovery  of  bacilli  in  the  sputum.  In  one  such  case  the  patient  had 
been  quite  recently  informed  by  a  throat  specialist  that  his  throat 
condition  was  simply  catarrhal,  and  that  his  cough  was  due  to  an  elongated 
uvula  which  had  been  promptly  ablated.  Finding  bacilli  in  the  sputum,  I 
gave  a  different  opinion.  The  patient  died  within  a  year  from  laryngeal 
and  pulmonary  tuberculosis. 

There  is  sometimes  considerable  difficulty  in  distinguishing  syphilis 
from  tubercle  of  the  larynx.  Syphilis  is,  as  a  rule,  more  rapidly 
destructive,  and  ulcerations  in  this  disease  are  generally  larger,  deeper, 
and  fewer  in  number.  The  syphilitic  ulcer  is  usually  surrounded  by  a  con- 
siderable amount  of  congestion  and  swelling.  In  all  doubtful  cases  iodide 
of  potassium  should  be  tried,  and  careful  examinations  of  the  sputum  made 
for  bacilli.  The  possibility  of  the  coexistence  of  tubercle  and  syphilis 
should  be  borne  in  mind. 

Malignant  disease,  as  a  rule,  occurs  at  a  later  period  of  life  than  that 
at  which  tuberculosis  is  most  commonly  met  with.  It  is  very  rare  before 
40.  Tumour  formation  is  much  more  definite  than  is  usual  in  tuberculosis, 
although  those  rare  cases  of  tuberculous  tumour  already  mentioned  must  be 
borne  in  mind.  Malignant  disease  is  more  likely  to  be  limited  to  one  side 
than  is  tubercle,  and  there  to  be  accompanied  by  a  considerable  amount 
of  swelling.  Often  it  is  extremely  difficult  to  distinguish  the  two,  and 
frequent  examinations  of  the  sputum  should  be  made. 

Prognosis. — The  prognosis  in  this  affection  is  always  comparatively 
grave,  although  of  late  years  treatment  has  been  much  more  successful 
in  early  and  limited  forms  of  the  disease  than  was  formerly  the  case. 
Whenever  there  is  continued  severe  pain,  accompanied  with  difficulty 
in  swallowing,  there  is  then  practically  no  hope.  The  same  is  true 
when  there  is  evidence  of  laryngeal  obstruction  and  inspiratory  dyspnoea. 
On  the  other  hand,  if  the  disease  is  confined  to  the  cords  or  interary- 
tenoid  fold,  and  the  general  condition  is  good,  the  pulse  quiet,  the  appetite 
hearty,  and  the  amount  of  disease  in  the  lungs  limited,  and  there  is  little 
or  no  fever,  there  is  good  prospect  that  the  disease  will  be  amenable  to 
local  and  general  treatment.  Where  the  epiglottis  is  affected,  cases  seldom 
if  ever  do  well.  Irritability  of  the  pharynx  and  larynx  is  always  a  bad 
sign. 

Treatment. — The  treatment  of  laryngeal  tuberculosis  may  be  divided 
into  general  and  local.  General  treatment  comprises  the  same  measures  which 
are  recommended  for  pulmonary  tuberculosis.  Patients  with  laryngeal  tuber- 
culosis do  not,  as  a  rule,  do  well  at  the  high  altitudes.  If  it  is  thought 
advisable  to  recommend  a  change  of  air,  Hastings,  Bournemouth,  Torquay, 
vol.  1. — 26 


4o2  GENERAL  DISEASES. 

Mentone,  or  Madeira,  are  among  the  resorts  which  have  been  found  most 
beneficial.  Dust  is  extremely  trying  to  laryngeal  cases.  Smoking  is 
probably  injurious,  and  should  be  forbidden  or  strictly  limited.  Local 
treatment  may  be  divided  into  palliative  or  symptomatic  and  radical,  the 
former  consisting  of  applications  to  relieve  pain  or  diminish  irritability, 
the  latter  of  treatment  calculated  to  promote  the  healing  of  lesions.  We 
shall  consider  the  latter  first.  The  most  important  method  at  present 
employed  is  the  application  of  lactic  acid  to  the  ulcerated  surface.  Lactic 
acid  is  employed  in  strengths  varying  from  20  per  cent,  up  to  the  pure  acid. 
It  is  applied  on  cotton-wool,  which  is  firmly  fixed  on  a  special  instrument, 
a  laryngeal  screw  holder.  Before  applying  it,  the  ulcerated  surface  may 
be  cleansed,  as  recommended  by  Bosworth ; — Dobell's  solution,  carbolic  acid, 
12  grs. ;  sod.  bicarb.,  |  drm. ;  glycer.,  2  oz. ;  borax,  1  drrn. ;  aqua  ad  Oj, 
being  applied  by  means  of  an  atomiser.  The  larynx  should  then  be  painted 
with  a  10  per  cent,  solution  of  cocaine.  Some  also  recommend  a  final 
application  of  cocaine  after  the  lactic  acid  has  been  applied.  Some  begin 
with  applications  of  20  per  cent.,  and  gradually  increase  the  strength  to  50 
per  cent. ;  but  Percy  Kidd,  who  has  had  a  very  large  experience  at  the 
Brompton  Hospital,  recommends  that  a  beginning  should  be  made  with  50 
per  cent.,  and  that  after  four  or  five  sittings  the  pure  acid  should  be 
used.  It  is  essential  that  the  application  of  the  lactic  acid  should  be 
thorough,  that  it  should  be  well  rubbed  in,  and  that  as  soon  as  the  patient 
has  got  over  the  effects  of  the  first  application,  a  second  should  be  made. 
The  lactic  acid  may  be  applied  daily,  or  every  two  or  three  days. 

The  cases  most  suitable  for  this  treatment  are  those  in  which  there  is 
little  lung  disease,  and  that  not  active,  in  which  there  is  ulceration  limited 
to  the  cords  or  inter-arytenoid  folds,  and  not  much  swelling  or  general 
infiltration.  It  is  very  important,  too,  that  there  should  be  little  irritability 
of  the  larynx.  Where  this  is  a  marked  feature,  no  great  amount  of  good 
is  to  be  expected  from  local  treatment  of  this  kind.  It  is  not  advisable  to 
employ  this  treatment  when  there  is  extensive  and  active  lung  disease. 
Lactic  acid  should  not  be  applied  unless  there  is  ulceration.  Sometimes 
the  application  of  lactic  acid  is  combined  with  curetting  or  cauterising  with 
the  galvano-cautery.  Curetting  was  recommended  by  Heryng  of  Warsaw, 
and  both  it  and  the  application  of  the  galvano-cautery  may  prove  beneficial 
by  paving  the  way  for  the  acid,  and  enabling  it  earlier  to  reach  the  actively 
tuberculous  process.  The  proposal  to  scarify  and  curette  before  actual 
ulceration  has  occurred,  in  order  that  the  acid  may  be  directly  applied  to 
the  diseased  tissue,  has  not  met  with  approval 

Palliative  treatment  consists  in  the  use  of  cocaine,  menthol,  morphine, 
orthoform,  and  iodoform.  For  the  relief  of  dysphagia,  cocaine  is  the  most 
valuable  remedy  we  have.  It  may  be  used  in  the  form  of  lozenges, 
pastilles,  etc.,  containing  -^  gr.  in  each,  two  or  three  of  which  may 
be  taken  before  meals.  A  2  per  cent,  solution  may  be  employed  in 
the  form  of  a  spray,  which  the  patient  may  use  himself  before  meals. 
Menthol  may  be  used  for  the  same  purpose  in  the  form  of  a  spray,  a  2 
per  cent,  solution  in  olive  oil  being  used,  or  twenty  drops  of  a  20  per  cent, 
alcoholic  solution  may  be  inhaled  on  a  respirator.  The  latter  solution  may 
be  applied  directly  to  the  larynx  to  diminish  irritability.  Morphine,  ortho- 
form,  and  iodoform  may  be  applied  by  means  of  insufflations.  Before  the 
introduction  of  lactic  acid,  iodoform  was  much  more  frequently  used  than 
it  is  now.  I  have  seen  great  benefit  from  the  daily  insufflation  of  a 
powder,  similar  to  that  mentioned  as  useful  in  ulceration  of  the  tongue 


TUBERCULOSIS.  403 

or  palate,  consisting  of  finely  powdered  iodoform  and  starch,  borax  or 
boric  acid,  a  grain  each,  with  \  gr.  of  hydrochloride  of  morphine.  Iodol 
has  more  recently  been  employed  for  the  same  purpose.  When  dysphagia 
is  not  relieved  by  these  remedies,  it  may  be  necessary  to  feed  the  patient 
by  means  of  a  soft  oesophageal  tube.  When  there  is  trouble  with  fluids, 
the  patient  may  find  it  easier  to  swallow  if  he  lies  prone  on  the  stomach, 
and  hangs  his  head  over  the  edge  of  the  couch  or  bed.  When  there  is 
urgent  dyspnoea,  tracheotomy  may  be  necessary. 

Trachea  and  Bronchi. 

Tracheal  tubercle  occurs  in  a  considerable  number  of  cases  in  the  later 
stages  of  pulmonary  tuberculosis,  but,  as  far  as  is  known,  is  never 
primary. 

Usually,  when  the  trachea  is  affected,  the  larynx  is  tuberculous  also,  but 
exceptionally  the  larynx  escapes.  The  bronchi  are  less  frequently  involved 
than  the  trachea.  That  the  infection  has  taken  place  through  the  sputum, 
is  shown  by  the  ulceration  occurring  exactly  in  the  track  which  it  has  had 
to  travel,  the  bronchus  leading  to  the  cavity  in  which  active  disease  is 
found  being  affected,  while  the  others  escape.  Ulceration  of  the  trachea 
was  found  in  eighty-four  out  of  454  fatal  cases  of  pulmonary  tuberculosis 
examined  at  the  Brompton  Hospital — a  proportion  of  20  per  cent,  of  the 
male  cases,  and  135  per  cent,  of  the  females.  There  was  bronchial  ulcera- 
tion in  sixteen  out  of  382  cases. 

Miliary  tubercles  in  the  trachea  are  seldom  met  with,  but  I  have  seen 
a  few  cases.  Ulcers  may  be  few  and.  shallow,  or  nearly  the  whole  interior 
may  be  ulcerated,  the  cartilages  being  exposed,  and  their  bare  extremities 
projecting  inwards  into  the  lumen  of  the  tube.  Sometimes  the  cartilages  are 
destroyed,  and  the  oesophagus  may  be  perforated,  subcutaneous  emphysema 
may  occur,  or  an  abscess  may  form  and  open  externally. 

There  are  no  characteristic  symptoms  of  tracheal  or  bronchial  ulceration 
which  can  enable  us  to  diagnose  it.  This  being  so,  nothing  need  be  said 
about  treatment. 

Lungs. 

It  required  a  genius  like  Laennec  to  recognise  the  unity  of  the  different 
forms  which  tuberculosis  assumes  in  the  lungs.  The  first  impression  on 
studying  the  various  lesions  is  that  of  inextricable  confusion,  and  there  is 
little  wonder  that,  arguing  from  a  clinical  as  well  as  a  pathological  stand- 
point, many  maintained  that  the  different  forms  of  pulmonary  tuberculosis 
were  not  merely  varied  types  of  the  same  disease,  but  were  so  many 
distinct  and  different  diseases.  This  was  held  to  be  the  case  with  regard 
to  miliary  tubercle,  caseous  pneumonia,  and  fibroid  phthisis,  which  were 
considered  to  have  little  or  nothing  in  common,  although  they  might  be 
met  with  simultaneously  in  the  same  lung. 

Acute  miliary  tuberculosis  of  the  lungs  has  already  been  sufficiently 
described.  In  this  form  of  the  disease  the  virus  is  disseminated  through  the 
lungs  by  means  of  the  blood  stream.  In  the  forms  we  are  now  about  to 
discuss  the  virus  is  principally  sown  through  the  medium  of  the  air 
passages. 


404  GENERAL  DISEASES 


Acute  Pneumonic  Phthisis. 

The  acute  pneumonic  form  of  pulmonary  tuberculosis  is  characterised  by 
a  rapid  caseation  of  lung  tissue.  It  may  be  either  a  primary  affection,  or, 
as  more  often  happens,  it  is  secondary  to  chronic  tuberculosis  of  the  lungs. 
We  shall  here  only  deal  with  the  primary  form,  premising  that  a  similar 
condition  may  supervene  in  a  case  of  chronic  phthisis. 

Morbid  anatomy. — Tracts  of  grey,  red,  or  caseous  consolidation  of 
various  sizes,  cavities  due  to  the  softening  of  the  centres  of  caseous  masses, 
and  granulations  in  other  parts  of  the  lungs,  are  the  principal  lesions 
observed  with  the  naked  eye.  The  grey  infiltration  or  consolidation  appears 
under  two  forms,  one  soft,  of  an  ashy  colour,  and  more  or  less  granular  on 
section,  and  another  firm,  glistening,  semi-transparent,  or  with  a  gelatinous 
appearance.  In  both  these  forms  there  is  a  total  absence  of  injection. 
In  the  red  infiltration  the  affected  tissue  is  hypersemic,  granular,  opaque, 
and  softer  than  the  grey.  The  tissue  affected  with  caseation  looks  as  if 
infiltrated  with  mastic.  It  is  yellow  or  greyish  white,  finely  granular,  dry, 
and  friable,  and,  as  in  the  grey  consolidation,  ansemic.  Its  vessels  and 
bronchi  can  no  longer  be  recognised,  and  the  latter  are  filled  with  exuda- 
tion. The  consolidations  in  some  cases  are  confluent,  affecting  the  whole 
or  the  greater  part  of  one  lobe,  as  in  lobar  pneumonia,  or  they  may  be 
scattered  and  have  a  broncho-pneumonic  distribution. 

Excavation  almost  invariably  arises  from  the  softening  or  sloughing  of 
caseous  masses,  which  may  or  may  not  be  associated  with  either  red  or 
grey  infiltrations.  On  section  small  collections  of  pus,  or  cavities  already 
formed,  of  various  sizes,  will  be  found  in  the  interior  of  these  consolidations. 
The  walls  of  these  abscesses  or  cavities  are  usually  composed  of  yellow 
caseous  matter.  Smaller  cavities  frequently  fuse  together,  forming  one 
larger  cavity  communicating  with  a  bronchus,  or  the  lung  may  be  honey- 
combed by  a  number  of  small  intercommunicating  cavities.  Softening  may 
occur  immediately  under  the  pleura,  resulting  in  its  necrosis  and  perfora- 
tion. Generally  the  pleura  over  a  superficial  caseous  mass  becomes  coated 
with  fibrinous  exudation.  In  the  remaining  portions  of  the  lung,  grey, 
white  and  yellow  tubercle  may  be  distributed  as  in  acute  miliary  tuber- 
culosis. 

Bacilli  may  sometimes  be  found  to  be  present  in  large  number  in  the- 
consolidated  areas.  Sections  of  these  parts  show  filling  of  the  alveoli  with 
fibrin  filaments  mingled  with  round  cells,  which  here  and  there  are- 
granular.  The  walls  of  the  vessels  whose  lumina  are  obliterated,  are  thick- 
ened and  infiltrated  by  small  cells.  Clumps  of  bacilli  may  be  found,  on 
staining  in  the  proper  manner,  in  the  perivascular  connective  tissue,  in  the 
thickened  vessel  wall,  and  in  some  of  the  peripheral  alveoli.  The  principal 
seat  of  the  bacilli  in  lobar  caseous  pneumonia  is  at  the  centre  of  the  inf  undi- 
bula,  where  the  small  cells  are  most  numerous. 

Emphysema  is  a  very  common  result  or  accompaniment  of  the  more 
acute  forms  of  pulmonary  tuberculosis.  It  is  often  general,  affecting  those 
parts  of  the  lungs  which  are  not  consolidated.  As  a  result  the  lungs  may 
be  very  bulky.  In  other  cases  it  is  limited  to  the  apices  or  to  the  free 
borders  of  the  lobes.  Patches  of  collapse  are  not  infrequent,  especially  in 
the  case  of  children.  This  form  of  acute  pulmonary  tuberculosis  is  often 
accompanied  by  tubercle  of  the  pleura,  or  by  a  fibrinous  exudation  on  the 
pleura,  with  or  without  effusion. 


TUBER  C  UL  OS  IS.  405 

Symptoms. — The  illness  may  commence  either  suddenly  or  gradually 
and  insidiously.  The  acute  onset  is  rare,  the  gradual  onset  is  much  the 
more  usual.  In  exceptional  cases  the  symptoms  attending  a  sudden 
invasion  may  closely  resemble  those  of  acute  pneumonia,  with  rigors, 
fever,  and  extreme  prostration.  Not  merely  the  invasion,  but  the  early 
period  of  illness,  may  closely  simulate  acute  pneumonia.  In  other  cases 
hemoptysis  is  the  earliest  symptom,  and  fever  and  prostration  appear 
later.  Both  rigors  and  haemoptysis  may  recur  during  the  course  of  the 
illness. 

The  symptoms  attending  the  gradual  and  more  usual  mode  of  onset 
are  vague,  and  are  often  misunderstood.  The  patient  is  perhaps  thought 
to  be  suffering  from  bronchial  catarrh,  from  the  effects  of  an  attack  of 
influenza,  from  rheumatism,  or  from  dyspepsia.  The  patient  feels  weak 
and  languid,  loses  appetite,  suffers  from  chilliness  and  aching  of  the  limbs, 
and  probably  bronchial  catarrh.  The  temperature,  if  taken,  is  found  to  be 
febrile.  Cough  is  seldom  absent  for  long.  In  some  cases  gastric  symptoms 
predominate,  and  the  main  features  of  the  cases  may  be  dyspepsia,  with 
discomfort  or  actual  pain  after  food,  more  or  less  complete  loss  of  appetite, 
constipation,,  and  sometimes  vomiting  and  diarrhoea.  Whether  the  onset 
is  acute  or  gradual,  the  later  symptoms  are  the  same. 

Physical  signs. — These  will  vary  according  as  there  are  scattered 
patches  of  consolidation  of  a  broncho-pneumonic  type,  or  a  considerable 
extent  of  consolidation  affecting  one  or  more  lobes.  As  bronchial  catarrh 
is  frequently  present,  rhonchi  may  be  audible  generally  over  the  lungs. 
In  the  areas  affected  by  consolidation,  the  usual  physical  signs  of  this 
condition — bronchial  breathing,  bronchophony,  and  increased  vocal  fremitus 
and  resonance — will  be  present.  Bales  may  or  may  not  be  present  over  the 
consolidated  area.  It  is  significant  of  these  cases  that  the  physical  signs 
persist  in  the  situation  where  they  first  appear,  although  other  parts 
are  successively  affected. 

The  fever  is  usually  high,  the  evening  temperatures  reaching  from  103° 
to  105°  F.  It  may  be  nearly  continuous,  or  assume  a  remittent  type,  and 
become  very  irregular.  The  pulse  rate  is  variable ;  it  may  be  rapid,  or  it 
may  not  exceed  80  in  the  minute.  The  respirations  are  quick,  ranging 
from  20  to  40  in  the  minute,  but  they  are  seldom  so  rapid  in  proportion 
to  the  pulse  as  in  acute  pneumonia.  There  is  generally  some  dyspnoea,  but 
often  not  to  such  an  extent  as  to  be  distressing  to  the  patient.  A  certain 
degree  of  cyanosis  is  not  unusual,  but  is  less  marked  than  in  the  pulmonary 
form  of  acute  miliary  tuberculosis.  Cough  may  be  slight  or  frequent  and 
troublesome,  and  the  expectoration  may  be  scanty  throughout  or  abund- 
ant. The  sputa  may  be  rusty  throughout,  or  may  consist  almost  entirely 
of  blood.  In  other  cases  they  are  mucous  at  first,  later  becoming  purulent. 
In  the  latter  stage,  elastic  fibres  are  generally  to  be  found.  Bacilli  are  j 
almost  always  present.  Gangrene  is  not  infrequent  as  a  terminal  process, 
and  may  impart  its  characteristic  odour  to  the  sputa. 

The  appetite  is  usually  in  abeyance  from  the  first.  The  tongue  pro- 
bably becomes  thickly  coated.  The  bowels  may  be  constipated  or  loose. 
The  body  rapidly  emaciates,  and  prostration  becomes  more  marked  as  the 
disease  progresses.  Profuse  sweating  is  not  uncommon.  Delirium,  restless- 
ness, and  insomnia  at  night  are  frequent  symptoms.  Albuminuria  is  not 
uncommon.     The  spleen  is  often  moderately  enlarged. 

Course. — The  course  of  the  disease  varies  in  duration.  Exceptional 
cases  terminate  in  ten  days  or  a  fortnight,  some  last  two  to  three  months, 


4o6  GENERAL  DISEASES. 

and  others  are  even  more  protracted.  Death  usually  ensues  from  asthenia 
and  prostration,  or  from  some  complication,  such  as  haemoptysis.  The 
patient  may  be  quite  conscious  to  the  end.  It  must  be  remembered  that 
cases,  which  to  begin  with  are  acute,  not  very  infrequently  pass  into  a 
chronic  condition,  and  may  subsequently  undergo  arrest. 

Diagnosis  and  prognosis. — When  the  invasion  is  sudden,  a  case 
of  acute  phthisis  at  the  outset  may  be  mistaken  for  ordinary  acute  pneu- 
monia, and  it  is  perhaps  the  protracted  course  which  first  excites  suspicion 
that  it  is  anything  different.  I  do  not  know  that  it  is  possible  to  make 
a  diagnosis  in  this  type  at  quite  an  early  stage.  Even  where  there  is 
evidence  of  previous  tubercle,  it  must  be  impossible  to  exclude  ordinary 
pneumonia  occurring  in  a  tuberculous  subject.  The  persistence  of  the 
fever,  and  the  gradual  extension  of  the  consolidation  to  other  parts,  without 
clearing  up  in  the  parts  first  affected,  are  important  points.  The  examina- 
tion of  the  sputum  for  tubercle  bacilli  and  elastic  tissue  will  help  to  clear 
up  the  diagnosis.  Empyema  following  on  pneumonia  may  be  mistaken  for 
tuberculosis,  but  in  this  case  there  is  generally  a  crisis  at  the  usual  time, 
and  a  gradual  return  of  the  fever  later  on.  Whenever  there  are  signs  of 
fluid,  an  exploratory  puncture  should  be  made.  Influenza  is  another 
malady  for  which  acute  pulmonary  phthisis  may  be  mistaken,  but  in  this 
case  the  mistake  can  only  be  made  at  the  beginning.  As  a  rule,  the 
disease  proceeds  to  a  fatal  termination.  In  rare  cases,  as  has  been  men- 
tioned, it  passes  into  a  chronic  condition,  and  becomes  one  of  ordinary 
chronic  phthisis. 

Treatment. — The  patient  should  be  kept  at  rest  in  bed  in  a  well- 
ventilated  room.  The  food  should  be  abundant,  and  adapted  to  the  condi- 
tion of  the  patient's  digestion.  Symptoms  must  be  treated  as  they  arise. 
Eor  details  as  to  treatment,  reference  must  be  made  to  the  following  section 
on  chronic  pulmonary  tuberculosis. 

Chronic  Pulmonary  Tuberculosis. 

Morbid  anatomy. — In  chronic  pulmonary  tuberculosis  or  phthisis 
pulmonalis  the  essential  character  of  the  lesions  is  fibrosis.  We  have  seen 
how  the  miliary  tubercle  may  undergo  a  fibrous  change  quite  independ- 
ently of  caseation,  and  also  how,  while  the  centre  may  caseate,  the  outer 
part  of  a  tubercle  may  become  fibrous.  In  all  cases  of  chronic  phthisis 
there  is  evidence  of  the  fibrous  change,  but  the  actual  chronic  lesions 
at  the  post-mortem  are  very  often  mingled  with  more  recent  morbid 
processes. 

The  disease  is  nearly  always  oldest  and  most  advanced  at  the  apices 
of  the  upper  lobes.  When  the  lower  lobes  are  affected,  their  apices  similarly 
are,  as  a  rule,  the  most  early  to  be  involved.  The  disease  is  usually  bilateral, 
although  one  lung  often  shows  older  and  more  extensive  disease  than  the 
other.  Cavities  are  almost  invariably  present.  These  are  often  of  a  large 
size.  Sometimes  a  whole  lobe,  and,  in  rare  cases,  nearly  an  entire  lung, 
may  be  destroyed.  The  commonest  situation  for  excavation  is  in  the 
upper  half  of  the  upper  lobe.  It  is  not  at  all  infrequent  for  it  to  occur 
in  the  lower  lobe,  near  its  apex.  Cavities  may  be  quite  superficial,  or 
they  may  be  separated  from  the  surface  by  lung  tissue  affected  with  fibrosis, 
or  otherwise  diseased.  The  cavities  may  be  rounded  in  shape  or  ramifying, 
multilocular,  and  extremely  irregular.  Their  walls  may  be  smooth  and 
fibrous,  and  lined  with  a  pyogenic  membrane,  or,  when  the  cavities  are 


TUBERCULOSIS.  407 

recent,  their  walls  may  be  irregular,  and  composed  of  softening  caseous 
material.  Very  frequently  they  are  traversed  by  trabecuke  formed  of  the 
thickened  remains  of  fibrous  septa  and  of  obliterated  vessels.  Such  trabe- 
cuke may  course  across  the  walls,  or  run  through  the  interior  of  the 
cavities. 

Cavities  nearly  always  at  the  autopsy  contain  more  or  less  purulent 
secretion,  but  we  have  evidence  that  during  life  perfectly  dry  cavities  may 
exist.  Indurated  tissue,  as  a  rule,  surrounds  the  chronic  cavities.  Such 
tissue  is  grey,  dense,  and  glistening,  and  frequently  embedded  in  it  are 
tubercles  either  fibrous  or  caseous.  Fibrosis,  however,  is  not  an  uncommon 
change  independently  of  excavation.  It  is  not  unusual  when  making  post- 
mortem examinations  on  persons  dead  from  accident  or  other  causes,  to  find 
masses  of  induration  at  one  or  other  apex.  These  on  being  cut  into  are  seen 
to  contain  in  their  interior,  dry  caseous  material,  or  cretaceous  nodules,  or 
both,  surrounding  which  are  strands  of  dense  pigmented  fibrous  tissue.  Such 
indurated  patches  are  frequently  observed  at  the  apices  of  the  lungs,  in 
cases  where  more  active  disease  occurs  below. 

In  these  cases  there  may  also  be  found  patches  of  consolidation  resembling 
the  grey  infiltration  of  acute  pneumonic  phthisis.  These  are  firm,  smooth, 
and  glistening,  and  tough  to  cut.  Caseous  nodules,  firm  or  softened,  may 
be  embedded  in  the  infiltration.  Various  forms  of  granulation  may  be 
irregularly  distributed  throughout  the  lungs.  These  are  often  grouped  in  a 
racemose  fashion.  They  are  firm  and  tough,  as  a  rule  deeply  pigmented, 
and  surrounded  by  fibrous  tissue.  Superimposed  on  these  older  lesions,  any  of 
those  met  with  in  acute  pneumonic  phthisis  or  in  acute  miliary  tuberculosis 
may  be  found.  Dilatations  of  the  bronchi  are  frequent  in  connection  with 
tuberculous  lesions.  They  are  most  common  in  chronic  cases  where  fibrosis 
is  a  predominating  feature,  but  they  may  occur  even  in  acute  cases.  The 
dilatations  are  usually  fusiform.  Less  commonly  the  dilated  bronchus 
terminates  in  a  globular  expansion,  but  it  is  difficult  to  distinguish 
bronchiectatic  cavities  from  those  which  have  formed  in  the  ordinary  way. 
In  the  ordinary  cavity  the  edge  of  the  bronchus  opening  into  it  is  sharply 
truncated,  and  its  mucous  membrane  is  swollen.  When  the  cavity  is  of 
old  standing,  this  distinction  may  disappear. 

In  chronic  phthisis,  emphysema  is  frequently  met  with  surrounding 
indurated  patches,  or  along  the  borders  of  the  lobes,  or  in  other  situations, 
the  bases  in  particular,  where  there  is  neither  excavation  nor  consolida- 
tion. The  emphysema  in  such  cases  is  not  uncommonly  of  the  atrophic 
type. 

The  pleura  is  nearly  always  involved  in  the  course  of  the  disease. 
Adhesions  are  almost  invariable.  Sometimes  the  lung  becomes  every- 
where united  to  the  parietes.  Sometimes  the  adhesions  are  limited  to 
the  apex.  In  the  latter  situation,  the  pleura  may  become  much  thickened, 
forming  a  layer  from  a  quarter  to  half  an  inch  thick.  On  section  it  may 
be  dense  and  fibrous  or  oedematous-looking.  Fibrinous  exudations  will  be 
present  where  there  are  more  recent  superficial  consolidations.  Effusions 
are  not  uncommon  at  one  or  both  bases.  Aneurysms  of  branches  of  the 
pulmonary  artery  are  very  frequent  in  cases  of  profuse  haemoptysis,  their 
rupture  being  by  far  the  most  usual  cause  of  this  event.  They  are  easily 
overlooked,  and  sometimes  are  only  discovered  after  carefully  cutting  up 
the  lungs  piece  by  piece.  In  size,  they  vary  from  a  small  pea  to  a  walnut, 
the  latter  size,  however,  being  very  exceptional.  They  are  not  uncommonly 
multiple,  and  a  dozen  or  more  may  be  present  in  one  case.    The  aneurysms 


408  GENERAL  DISEASES. 

may  be  met  with  on  the  walls  of  large  cavities,  but  it  is  more  common  to 
find  them  in  medium-sized  vomicae,  and  occasionally  they  occur  as  round 
pedunculated  tumours,  lying  in  cavities  little  bigger  than  themselves.  They 
sometimes  form  in  connection  with  quite  small  branches  of  the  pulmonary 
artery.  The  mode  of  production  of  these  aneurysms  is  the  same  as  that  of 
septic  aneurysms  elsewhere.  First,  there  is  an  inflammatory  process  in  the 
wall  of  the  vessel,  a  suppurative  arteritis,  by  which  the  middle  coat  is 
destroyed.  The  vessel  then  gradually  dilates,  and  the  outer  and  inner  coats 
become  expanded,  the  former  at  the  pedicle  being  continuous  with  the  wall 
of  the  cavity.  The  bronchial  glands  are  very  frequently  tuberculous  in 
pulmonary  tuberculosis.  In  acute  cases,  one  or  more  are  generally  caseous ; 
in  chronic  cases,  a  fibroid  or  calcareous  condition  is  not  at  all  uncommon. 
The  larynx  and  intestines  are  very  often  secondarily  affected.  These 
and  other  concomitant  tuberculous  complications  have  been  already  fully 
described  under  special  headings. 

Arrested  tuberculosis — Everyone  who  has  much  experience  in  post- 
mortem examinations  must  be  struck  with  the  comparative  frequency  of 
evidences  of  healed  tubercle  unexpectedly  found  in  persons  who  have  died 
from  other  causes.  The  most  usual  lesions  met  with  are  fibrous,  calcareous, 
or  cheesy  masses,  embedded  in  the  apices  of  the  lungs,  to  which  allusion 
has  already  been  made,  and  calcareous  or  fibrous  and  pigmented  bronchial 
or  mesenteric  glands.  The  relative  frequency  of  such  lesions  has  been 
variously  estimated:  Heitler  of  Vienna,  16,562  autopsies,  4  per  cent.; 
Osier,  1000  autopsies,  7"5  per  cent. ;  Fowler,  1943  autopsies,  9  per  cent. ; 
Sidney  Martin,  445  autopsies,  9-4  per  cent. ;  Coats,  103  autopsies,  23  per 
cent.  Such  lesions  are  very  frequently  met  with  in  patients  dying  from 
chronic  pulmonary  tuberculosis. 

Associated  lesions. — Digestive  system. — The  morbid  changes  in  the 
stomach  are  chiefly  of  a  catarrhal  nature  affecting  the  glandular  structure, 
and  accompanied  by  general  thickening  of  the  mucous  membrane.  Rarely, 
simple  ulcers  have  been  found,  but  it  is  doubtful  whether  the  association  is 
other  than  accidental. 

The  intestinal  tract  is  similarly  likely  to  be  affected  with  catarrh,  and 
simple  as  well  as  tuberculous  ulcers  may  be  present.  In  the  large  intestine 
sloughing  of  the  mucous  membrane,  and  the  formation  of  a  croupous  false 
membrane,  sometimes  occurs.  Amyloid  degeneration  of  the  intestinal 
mucous  membrane  is  not  infrequently  observed  in  chronic  cases,  and  the 
stomach  occasionally  is  similarly  affected. 

Fistula  in  ano,  and  its  connection  with  tuberculosis,  has  been  already 
discussed. 

Decided  fatty  degeneration  of  the  liver  is  met  with  in  about  30 
per  cent,  of  the  cases.  The  organ,  as  usual,  is  enlarged,  pale,  anaemic, 
greasy,  and  abnormally  soft  and  friable.  Amyloid  degeneration  of  the  liver 
occurs  in  about  10  per  cent,  of  the  cases.  Chronic  congestion  or  nutmeg 
liver  is  rare.  Cirrhosis  is  too  commonly  associated  with  tubercle  for 
this  to  be  merely  accidental.  In  such  cases  there  is  nearly  always  a 
history  of  alcohol,  which,  while  directly  causing  the  cirrhosis,  has  probably 
predisposed  to  tubercle. 

The  pancreas,  as  a  rule,  shows  no  characteristic  change. 

The  spleen  in  the  more  acute  cases  is  often  enlarged  and  softened. 
Amyloid  degeneration  is  more  common  in  the  spleen  than  in  the  liver,  and 
may  occur  in  the  diffuse,  or  in  the  sago  form.  In  the  diffuse  form,  the  organ 
may  be  considerably  enlarged,  and  very  firm  and  heavy,  the  greater  part  of 


TUBERCULOSIS. 


409 


the  tissue  being  affected ;  in  the  sago  form,  the  degeneration  is  limited  to 
the  Malpighian  bodies. 

The  heart  is  generally  small,  but  is  less  diminished  in  size  than  in  some 
other  wasting  diseases.  The  atrophy,  as  a  rule,  affects  both  sides  equally, 
but  the  right  side  may  be  dilated,  especially  in  very  chronic  cases.  The 
muscle  is  pale,  and  under  the  microscope  may  show  brown  atrophy,  or  a 
certain  amount  of  fatty  degeneration.  While  mitral  stenosis  is  rare,  other 
forms  of  valvular  lesion  are  probably  neither  more  nor  less  frequent  than 
they  are  in  the  case  of  other  diseases.  Congenital  disease  of  the  heart  is 
often  associated  with  pulmonary  tuberculosis. 

Thrombosis  of  the  popliteal,  femoral,  or  other  veins  is  a  not  uncommon 
occurrence,  commencing  a  week  or  two  before  the  fatal  termination  of  a 
case  of  phthisis.  Thrombosis,  although  more  frequent  towards  the  end, 
may  occur  at  an  earlier  stage  and  be  recovered  from. 

Genito-urinary  system. — Amyloid  disease  of  the  kidneys  is  a  common 
result  of  chronic  phthisis.  As  to  what  its  actual  frequency  is,  very  different 
estimates  have  been  given.  In  many  cases  where  examination  with  the 
naked  eye,  after  staining  the  section  with  iodine,  shows  nothing  abnormal, 
microscopic  examination,  after  staining  with  methyl-violet,  methylene- 
blue,  or  methyl-green,  reveals  the  presence  of  amyloid  change  in  the 
glomeruli.  Congestion  and  chronic  interstitial  nephritis  are  among  the 
other  changes  met  with.  No  changes,  other  than  tuberculous,  are  likely  to 
be  found  in  the  bladder  or  genital  organs. 

The  nervous  system  shows  no  characteristic  lesion  independent  of 
tubercle. 

Symptoms. — The  usual  symptoms  of  pulmonary  tuberculosis  are  cough 
and  expectoration,  emaciation,  fever,  sweating  at  night,  loss  of  appetite  and 
dyspepsia,  shortness  of  breath,  and,  probably  at  some  period  of  the  disease, 
haemoptysis.  The  lesions  in  the  lungs  generally  give  rise  to  characteristic 
physical  signs,  as  already  observed.  The  older  descriptions  divided  the 
illness  into  three  stages.  In  the  first  stage  there  was  simply  the  deposit  of 
tubercle ;  in  the  second,  there  was  consolidation  and  softening ;  and  in  the 
third,  cavities  had  formed.  While,  however,  one  part  of  the  lung  may  be 
in  one  stage,  another  part  is  in  another.  No  useful  purpose  is  served 
by  giving  separate  descriptions  of  the  symptoms  in  different  stages.  The 
disease  may  be  arrested  at  any  stage,  and  the  patient  with  cavities  in  his 
lungs  is  frequently  much  less  ill,  and  has  better  prospects  of  life,  than  when 
the  morbid  process  has  not  yet  reached  the  cavity  stage. 

The  mode  of  onset  of  chronic  pulmonary  tuberculosis  is,  as  a  rule,  very 
insidious.  The  patient  gets  out  of  health,  loses  his  appetite,  is  easily  tired," 
finds  himself  short  of  breath,  and  probably  has  a  cough,  with  mucous  expec- 
toration. If  the  temperature  be  taken,  it  will  likely  be  found  to  be  up 
in  the  afternoon  or  evening.  Sometimes  haemoptysis  is  apparently  the 
first  symptom,  although  on  investigation  it  will  generally  be  found  that  the 
patient  has  been  out  of  health  before.  In  other  cases,  the  illness  com- 
mences with  pleurisy.  Sometimes  the  patient  first  consults  the  doctor  on 
account  of  hoarseness. 

Sometimes  during  the  onset,  pulmonary  and  larnygeal  symptoms  are 
conspicuous  by  their  absence.  This  is  not  uncommonly  the  case  with  old 
people  and  children.  In  these  cases,  there  is  failure  of  health  without 
obvious  cause.  The  patient  complains  of  weakness,  lassitude,  and  loss  of 
flesh,  and  probably  if  his  temperature  be  taken  there  will  be  found  to  be 
some  fever.     Gastric  derangement  is  not  an  infrequent  symptom  at  the 


4io  GENERAL  DISEASES. 

onset.  It  shows  itself  in  the  form  of  atonic  dyspepsia,  with  a  red  or 
furred  tongue,  pain  after  food,  anorexia,  and  sometimes  vomiting. 
Amenorrhoea  in  females  and  anaemia  are  other  common  symptoms  of  the 
early  stage.  We  shall  now  proceed  to  describe  the  principal  symptoms  in 
detail. 

Cough. — Cough  is  one  of  the  earliest  as  well  as  one  of  the  most  per- 
sistent symptoms.  In  the  early  stages  it  is  often  short,  dry,  and  hacking, 
occurring  principally  in  the  morning  and  evening.  Later  it  often  becomes 
noisy,  paroxysmal,  and  distressing.  Sometimes  the  cough  is  excited  by 
food,  and  after  a  meal  may  be  so  severe  as  to  be  terminated  by  vomiting. 
It  often  becomes  more  frequent  and  more  distressing  as  the  disease 
advances.     It  is  apt  to  be  aggravated  by  excitement  or  exertion. 

Sputum. — If  there  is  any  expectoration  in  the  early  stages,  it  is 
probably  simply  mucus  with  perhaps  carbon  particles.  It  next  becomes 
muco-purulent,  with  greenish  or  yellowish  streaks,  and  later,  thicker 
and  more  tenacious,  while  a  greenish  yellow  tinge  pervades  the  whole. 
Frequently  the  sputa  acquire  a  nummulated  shape.  The  quantity  of  the 
expectoration  in  the  twenty-four  hours  varies  from  a  drachm  to  6  or  10 
oz.,  or  even  more.  Analysis  has  shown  that  the  sputa  contain  94  per  cent. 
of  water,  together  with  mucin,  extractives,  albumin,  fat,  and  inorganic 
matter  consisting  of  chloride  of  sodium  and  phosphates.  They  have  a  faint 
sweetish  odour,  but  ordinarily  no  foetor.  Occasionally  calcareous  masses 
are  expectorated.  These  point  to  the  existence  of  an  old  cured  lesion. 
Such  calcareous  masses  are  not  unfrequently  found  embedded  in  the  lung 
at  the  centre  of  such  obsolete  tuberculous  nodules.  They  vary  in  size  from 
a  coriander  to  a  cherry  sbone.  As  many  as  five  hundred  have  been  known 
to  be  expectorated  in  an  individual  case.  In  a  cover -glass  spechnen  of 
sputum  may  be  seen  epithelial  cells  from  the  mucous  membrane  and  the 
pulmonary  alveoli,  leucocytes,  and  fatty  debris.  Importance  has  been 
attached  by  Teichmuller  to  eosinophile  cells,  their  presence  being  con- 
sidered by  him  a  favourable  sign,  while  their  rapid  disappearance  or 
persistent  absence  is  of  bad  omen. 

Bacilli. — The  presence  of  the  tubercle  bacillus  is  the  only  really 
characteristic  feature  of  the  sputum  of  pulmonary  tuberculosis.  It  is 
never  found  in  any  expectoration,  except  that  from  a  phthisical  patient.  It 
is  not  always  to  be  found  in  phthisis,  but  if,  after  several  examinations  of 
the  sputum  by  an  experienced  observer,  no  bacilli  are  found,  it  is  very 
unlikely  that  the  case  is  one  of  active  tuberculosis.  The  mode  of  examining 
sputum  for  bacilli  has  already  been  described. 

While  the  presence  of  the  bacilli  in  the  sputum  has  a  very 
important  diagnostic  value,  little  help  in  prognosis  is  afforded  by  repeated 
examinations.  Changes  in  the  appearances  of  the  bacilli  are  of  no  moment, 
and  differences  in  their  number  do  not  help.  The  disappearance  of  bacilli 
from  the  sputum,  however,  over  a  certain  period  of  time  is  of  great 
importance,  and  if  associated  with  favourable  symptoms  points  to  arrest  of 
the  disease.  When  examinations  are  made,  the  patient  himself  should,  as  a. 
rule,  not  be  informed  of  their  results.  If  the  bacilli  are  few,  he  is  apt  to  be 
unduly  elated ;  if  they  are  many,  to  be  unnecessarily  depressed.  Better 
there  should  be  no  examinations  at  all,  after  the  first  for  diagnostic  pur- 
poses, than  that  a  morbid  anxiety  regarding  bacilli  should  be  created  and 
fostered. 

Elastic  fibres. — The  presence  of  elastic  fibres  in  the  sputum  is  only 
second  in  importance  to  that  of  the  bacilli.     Their  presence  shows  that 


TUBERC  UL  OSIS.  4 1 1 

softening  is  in  progress.  The  fibres  are  short  and  narrow,  with  wavy 
outline  and  double  contour.  An  alveolar  arrangement  of  the  fibres  is  a 
great  help  to  diagnosis.  The  fibres  resist  the  action  of  acetic  acid.  By 
heating  the  sputum,  till  it  boils,  with  an  equal  amount  of  a  solution  of  caustic 
soda,  20  grs.  to  the  ounce,  allowing  this  to  stand,  and  examining  the 
deposit,  as  recommended  by  Fenwick,  the  fibres  are  most  readily  discovered. 

Care  should  be  taken  not  to  mistake  foreign  bodies,  such  as  fibres  of 
wool,  cotton,  or  vegetable  substances  accidentally  present,  for  elastic  tissue. 
It  is  advisable  to  use  a  silk  cloth  for  wiping  slides  and  cover -glasses,  when 
examining  for  elastic  tissue. 

Haemoptysis  is  a  very  important  symptom,  not  simply  on  account  of  its 
frequency,  but  because  its  occurrence  is  very  strong  presumptive  evidence 
of  the  existence  of  tubercles.  It  may  occur  at  any  stage  of  the  disease.  In 
a  considerable  proportion  of  cases,  it  is  an  early  symptom,  sometimes  the 
earliest.  It  may  be  the  immediate  cause  of  death.  In  probably  about 
three-fourths  of  all  cases  of  chronic  pulmonary  tuberculosis,  haemoptysis 
occurs  during  some  period  of  the  illness. 

Among  my  hospital  out-patients,  I  found  a  history  of  haemoptysis  in 
about  45  per  cent,  of  the  phthisical.  Thus,  out  of  1670  phthisical  patients,  in 
742  haemoptysis  occurred,  either  before  or  during  their  period  of  attendance. 
In  about  a  sixth  of  the  whole  number  of  cases,  the  haemorrhage  was  a  large 
one;  in  about  a  fifth,  it  was  a  small  amount;  and  in  the  remaining  fraction, 
consisting  of  about  a  twelfth  of  the  whole,  it  only  amounted  to  streaks  of 
blood  in  the  sputum.  Eeginald  Thompson  states  that  out  of  5000  cases 
of  well-marked  pulmonary  disease  among  his  out-patients,  in  45  per  cent, 
haemorrhage  of  a  decided  kind  occurred.  Pollock  gives  a  percentage  of  584, 
founded  on  an  experience  of  1200  out-patient  cases,  and  C.  T.  Williams  out  of 
1000  private  cases  found  569  affected  with  bleeding,  or  57  per  cent.  My 
experience  is,  that  haemoptysis  is  considerably  more  frequent  in  the  male 
sex  than  in  the  female,  and  this  is  not  explained  by  the  larger  number  of 
male  cases  of  phthisis  that  one  sees.  A  larger  proportion  of  males 
relatively  have  haemoptysis.  Thus  49  per  cent,  of  my  male  cases  spat 
blood,  while  only  39  per  cent,  of  the  females  were  so  affected.  Pollock 
found  that  of  351  cases  of  profuse  haemoptysis,  267  were  males,  84  females. 

Haemoptysis  is  comparatively  rare  at  the  two  extremes  of  life,  children 
and  old  people  being  relatively  less  subject  to  it.  Occasionally,  however, 
they  may  have  large  haemorrhages.  Haemoptysis  appears  from  statistics  to 
be  more  frequent  during  the  summer  months  than  at  other  times  of  the 
year.  Haemoptysis,  as  has  been  pointed  out,  may  be  the  first  obvious  symp- 
tom of  the  disease.  On  the  whole  it  is  more  frequent  in  the  later  stages. 
Very  often  the  patient  suffers  from  several  attacks  in  the  course  of  his  illness. 
Care  must  be  taken  to  distinguish  between  haemoptysis  on  the  one  hand, 
and  epistaxis,  bleeding  from  the  gums  and  fauces,  etc.,  and  haematemesis  on 
the  other. 

Sometimes  the  patient  thinks  he  can  feel  the  blood  coming  from  a 
particular  part  of  the  lungs,  but  such  sensations  cannot  be  depended  on. 
The  blood  brought  up  from  the  lungs  is  nearly  always  bright  and  frothy, 
and  is  fluid  and  not  clotted.  In  this  way  it  contrasts  with  blood  from  the 
stomach,  which  is  either  a  dark  grumous  fluid,  like  coffee-grounds,  or  may 
be  partly  composed  of  clots.  A  large  quantity  may  come  up  at  once  or,  as 
more  frequently  happens,  a  number  of  separate  mouthfuls  are  brought  up. 
Although  haemoptysis  usually  subsides  within  a  short  time,  cases  occur 
where  the   patient   continues   to   bring  up  quantities  of  blood  for  days 


412  GENERAL  DISEASES. 

together.  The  sputa  are  generally  stained  for  some  days  after  the  first 
bleeding  has  occurred.  This  is  a  point  of  great  importance,  as  distinguishing 
from  haemateraesis. 

At  the  Brompton  Hospital,  one  out  of  every  thirteen  or  fourteen  deaths 
is  from  haemoptysis.  Out  of  915  deaths  from  pulmonary  tuberculosis,  there 
were  sixty-six  from  haemorrhage,  giving  a  proportion  of  7 '2  per  cent.  In 
two-thirds  of  the  cases,  pulmonary  aneurysms  were  found.  Hospital  experi- 
ence must  necessarily  place  the  death  rate  from  haemoptysis  too  high.  Cases 
with  haemoptysis  are  admitted  on  account  of  urgency,  and  therefore  are 
present  beyond  their  normal  proportion.  In  the  case  of  a  hospital  which 
admitted  haemoptysis  cases,  but  not  ordinary  phthisical  cases,  it  would 
appear  that  nearly  every  patient  with  phthisis  died  from  haemoptysis — a 
reductio  ad  absurdum.  West's  estimate  of  less  than  3  per  cent,  is 
probably  correct. 

Shortness  of  breath  is  a  very  constant  accompaniment  of  pulmonary 
tuberculosis.  It  is  seldom,  unless  from  some  complication,  that  it  amounts 
to  actual  dyspnoea.  Ordinarily  it  is  only  experienced  on  exertion,  when 
the  patient  mounts  a  stair,  or  walks  on  rising  ground.  As  long  as  he  is  at 
rest  or  on  level  ground  he  remains  unembarrassed  in  his  breathing.  But 
although  the  patient  may  be  unconscious  of  it,  often  the  physician  will 
observe  the  breathing  is  more  rapid  than  normal.  Cyanosis  is  a  very 
unusual  phenomenon,  except  in  advanced  cases,  and  in  cases  where  there  is 
extensive  basic  disease. 

Emaciation. — "Wasting  of  the  body  has  been  looked  on  as  the  most 
characteristic  feature  of  the  malady,  as  shown  by  the  names  consumption 
and  phthisis.  It  is  nearly  always  present,  and  progresses  as  the  disease 
advances.  In  very  chronic  cases,  the  patient  may  continue  well  nourished 
or  put  on  weight,  even  while  the  symptoms  show  that  the  disease  is  active. 
Such  cases  are  very  exceptional.  Under  treatment,  hygienic,  climatic,  and 
medicinal,  the  patient  in  favourable  cases  steadily  puts  on  weight.  When 
the  disease  is  arrested,  the  patient  may  attain  a  greater  bodily  weight  than 
at  any  previous  time  of  his  life. 

Loss  of  strength  and  energy  usually  accompanies  loss  of  weight  in  the 
progress  of  the  disease.  Lassitude  is  often  most  noticeable  when  the 
patient  wakes  in  the  morning,  and  it  is  a  common  complaint  that  he  feels 
more  tired  then  than  when  he  went  to  bed. 

Pain  is  not  a  very  characteristic  symptom,  and  when  present  is  usually 
caused  by  involvement  of  the  pleura.  The  patient  may  complain  of  pain 
in  the  side,  or  in  the  region  of  the  clavicle,  or  in  the  scapular  region. 
Muscular  pains  over  the  lower  ribs  may  result  from  cough.  There  is  often 
tenderness  to  percussion  on  the  affected  side,  especially  in  the  case  of 
women. 

Indigestion. — Functional  disturbances  of  the  digestive  system  are  among 
the  most  constant  and  important  of  the  symptoms  unconnected  with  the 
respiratory  tract.  Loss  of  appetite  is  frequent  at  an  early  stage. 
Generally,  there  is  a  distaste  for  all  kinds  of  food,  but  especially  for  fats. 
The  patient  complains  of  a  feeling  of  weight  and  discomfort  after  a 
meal,  and  is  likely  troubled  with  acid  eructations.  A  red  line  on  the 
margin  of  the  gums  is  not  unusual,  but  has  no  special  significance. 
The  tongue,  in  most  cases,  is  fairly  clean,  or  pale  and  only  slightly  furred. 
In  the  later  stages  it  may  be  thickly  coated,  and  the  mouth  and  throat  feel 
dry  and  sticky,  especially  in  the  morning.  Vomiting  is  a  common  symptom, 
especially  among  women  and  in  the  early  stages.     As  a  rule,  it  only  occurs 


TUBER  C  UL  OSIS.  4 1 3 

after  meals,  and  may  then  be  preceded  by  a  fit  of  coughing.  It  is  more 
common  after  the  evening  meal  than  after  the  morning.  The  vomiting 
produced  in  this  way  probably  depends  on  an  abnormal  reflex  excitability 
of  the  gastric  fibres  of  the  vagus.  In  the  early  stages,  constipation  is  more 
frequent  than  regularity  of  the  bowels  or  diarrhoea.  Diarrhoea  usually 
occurs  late,  from  ulceration  or  catarrh  of  the  intestine.  We  have  already 
referred  to  the  gastric  form  of  onset  of  the  disease. 

Fever. — Eise  of  temperature  is  a  constant  accompaniment  of  tubercle 
in  its  active  stages.  Much  study  has  been  devoted  to  the  types  of  pyrexia 
in  pulmonary  tuberculosis.  The  numerous  classes  which  have  been 
described  may  with  advantage  be  reduced  to  two :  (1)  Where  the  morning 
temperature  is  normal  or  subnormal  and  there  is  slight  or  more  marked 
evening  pyrexia ;  (2)  where  there  is  more  or  less  constant  pyrexia,  but 
with  evening  temperatures  distinctly  higher  than  the  morning. 

The  highest  temperature  is  usually  met  with  about  6  or  8  p.m.,  then 
there  is  a  gradual  fall  until  the  lowest  temperature  is  reached  between  6 
or  8  a.m.,  after  which  it  gradually  rises  again.  There  is  no  exact  regularity 
as  to  the  time  of  the  highest  and  lowest  temperatures.  The  highest 
temperature  reached,  as  a  rule,  does  not  exceed  103°,  but  rarely  it  may 
be  104°,  and  very  rarely  105°.  The  lowest  temperature  may  be  normal 
or  subnormal.  The  remissions  or  differences  between  the  highest  and  lowest 
temperatures,  in  mild  cases,  do  not  amount  to  more  than  1°  or  2°, 
but  in  severe  cases  may  be  as  much  as  4°  or  5°,  or  even  more. 
Cceteris  paribus,  the  high  temperatures  with  marked  remissions  are  met 
with  in  cases  where  the  disease  is  active  and  advancing,  and  caseation  a 
prominent  feature.  With  quiescence  of  the  disease,  the  fever  may  entirely 
disappear.  Its  return  after  disappearance  is  a  bad  sign,  and  points  to 
extension  and  renewed  activity  of  the  disease.  Fever  of  a  continuous  type, 
with  little  difference  between  morning  and  evening  temperature,  generally 
points  to  miliary  infiltration. 

Exertion  and  excitement  are  apt  to  temporarily  increase  the  pyrexia. 
Accidental  causes  may  also  interrupt  the  regularity  of  a  temperature  chart, 
even  when  a  patient  is  confined  to  bed.  It  should  be  remembered  that 
although  higher  evening  temperatures  are  the  rule,  sometimes  an  inverse 
type  is  met  with  in  which  the  morning  temperatures  are  the  higher. 
This  inverse  type,  like  the  continuous  type,  as  a  rule,  points  to  miliary 
infiltration.  As  observed  by  Traube,  intermitting  fever  may  so  charac- 
terise pulmonary  tuberculosis  that  it  may  be  mistaken  for  malaria. 
There  may  then  be  definite  rigors,  which  may  also  occur  in  other  cases. 
Osier  remarks  th£t  in  Philadelphia  and  Baltimore,  where  ague  prevails, 
scores  of  cases  of  early  tuberculosis  are  treated  every  year  for  ague. 

Sweating  at  night  is  a  very  usual  and  characteristic  symptom.  It 
commonly  occurs  towards  the  early  morning,  when  the  patient  may  wake 
up  bathed  in  perspiration.  It  is  usually  accompanied,  in  febrile  cases, 
with  a  decided  fall  of  temperature.  It  generally  points  to  activity  and 
progress  of  the  disease,  and  as  a  rule  disappears  with  cessation  of  fever 
and  arrest  of  the  disease.  Profuse  sweats  are  very  exhausting  as  well  as 
a  source  of  great  discomfort  to  the  patient.  Pityriasis  versicolor  may 
often  be  noticed  among  hospital  patients,  and  is  probably  connected  with 
too  infrequent  change  of  underclothing  and  too  few  ablutions.  The  so- 
called  chloasma  phthisicorum  is  decidedly  rare.  A  slight  degree  of  club- 
bing of  the  fingers  is  not  uncommon  in  chronic  cases,  but  one  seldom  sees 
extreme  degrees  of  this  condition,  such  as  are  met  with  in  bronchiectasis,  etc. 


414  GENERAL  DISEASES. 

Pulse-rate. — This  is  one  of  the  hest  guides  to  the  condition  of  the  patient. 
The  pulse  is  rapid  when  the  disease  is  active  and  progressive.  It  quietens 
down  again  when  the  disease  becomes  arrested.  The  rate  of  the  pulse 
bears  no  necessary  relation  to  the  temperature.  It  may  be  as  rapid  in  the 
morning  when  the  temperature  is  nearly  normal  as  it  is  in  the  evening 
when  there  is  fever.  In  the  later  stages  the  pulse  becomes  weak  as  well 
as  rapid,  and  this  combination  is  a  bad  sign. 

The  blood. — No  special  changes  are  observed  in  the  blood.  The  red 
corpuscles  are  diminished  in  number,  and  are  deficient  in  haemoglobin. 
The  blood  platelets  are  increased  in  number,  but  this  is  by  no  means  a 
peculiarity  of  tuberculosis 

Urinary  symptoms — There  are  no  special  urinary  symptoms  unless 
the  kidneys  themselves  become  diseased.  Amyloid  disease  is  not  un- 
common in  the  later  stages,  and  then  the  urine  contains  albumin  and 
perhaps  a  very  few  tube  casts.  Albuminuria  may  also  occur  simply  as  the 
result  of  fever.  The  symptoms  present  when  tubercle  affects  the  urinary 
tract  are  described  under  a  special  heading.  In  the  case  of  females,  when 
phthisis  attacks  at  the  age  of  puberty,  the  onset  of  menstruation  may  be 
indefinitely  delayed.  The  catamenia  .are  frequently,  sooner  or  later,  sus- 
pended during  the  course  of  phthisis,  and  before  complete  arrest  generally 
become  irregular  either  in  time  or  quantity.  The  presence  of  phthisis  does 
not  appear  to  interfere  with  impregnation.  Phthisical  women,  indeed, 
seem  to  be  quite  as  fertile  as  the  non-phthisical. 

It  would  be  needless  to  say  that  the  sexual  appetite  is  diminished  pari 
passu  with  the  failure  in  health,  if  it  were  not  that  a  false  impression  to 
the  contrary  has  prevailed.  Louis  wrote  very  sensibly  in  regard  to  this 
point:  "Presque  tous  ceux  aux  quels  j'ai  demande  si  leur  penchant  a 
l'amour  ^tait  plus  developpe*  qu'en  bonne  sante,  indiquaient  par  leurs 
reponses  que  la  question  leur  paraissait  pour  ainsi  dire  ridicule." 

Nervous  symptoms. — The  hopefulness  which  hardly  ever  leaves  the 
patient,  until  death  closes  the  scene,  is  quite  characteristic  of  the  disease. 
It  is  seldom,  even  in  the  last  stages,  that  the  patient  recognisas  how  ill  he  is. 
Almost  dying  patients  are  constantly  being  brought  to  the  hospital,  firmly 
imbued  with  the  belief  that  if  they  are  only  admitted  they  will  be  well  in 
a  short  time.  The  mental  faculties  as  a  rule  remain  unimpaired  to  the 
end.  Occasionally  insanity  complicates  phthisis,  but  it  has  not  been 
shown  that  more  than  the  average  number  of  phthisical  patients  become 
insane. 

Symptoms  of  peripheral  neuritis  have  sometimes  been  observed.  That 
neuritis  may  be  produced  by  tuberculosis  is  undoubted,  but  I  have  never 
myself  seen  it  associated  with  tubercle,  except  when  there  was  a  history 
of  drink.  In  nearly  all  the  fatal  cases  of  alcoholic  neuritis,  pulmonary 
tubercle  has  been  found.  In  non-alcoholic  cases,  the  cause  of  the  neuritis 
is  the  toxine  produced  by  the  bacillus,  and  not  the  bacillus  itself.  Menin- 
gitis or  tuberculous  tumour  in  the  brain  will  give  rise  to  special  symptoms, 
which  are  elsewhere  described.  Generally  these  complications  carry  the 
patient  quickly  off. 

Physical  signs. — The  chief  physical  signs  met  with  in  chronic  pul- 
monary tuberculosis  are  those  of  consolidation,  softening,  and  excavation. 

In  early  cases,  the  physical  signs  may  afford  but  little  help  in  diagnosis, 
and  more  dependence  has  to  be  placed  on  symptoms  and  on  examinations 
of  the  sputum.  The  mere  presence  of  miliary  tubercle  does  not  alter  the 
resonance  of  the  percussion  note,  nor  does  it  necessarily  give  rise  to  any 


TUBER  C  UL  OSIS.  4 1 5 

abnormal  auscultatory  signs.  It  is  useful  to  bear  in  mind  that  commonly 
the  earlier  formations  of  tubercle  occur  in  the  upper  parts  of  the  upper 
lobes,  and  that  later  the  disease  is  nearly  always  more  advanced  about  the 
apices.  Although  both  lungs  are  usually  affected,  it  is  very  seldom  that 
they  are  equally  so,  and  for  a  long  time  the  amount  of  disease  in  the  sounder 
lung  may  not  be  sufficient  to  produce  signs  of  its  presence. 

A  good  deal  of  importance,  as  an  early  sign,  has  been  attached  to  a  wavy 
interrupted  character  of  the  inspiratory  breath  sounds  over  a  localised  area. 
Such  breath  sounds  are  not  uncommonly  audible  over  the  second  intercostal 
space  near  the  sternum  in  early  cases.  It  is  probable  that  the  presence  of 
tubercle,  acting  as  an  obstacle  to  the  entrance  of  air  into  the  affected 
part  at  the  same  time  as  into  the  rest  of  the  lung,  causes  the  inspiratory 
sound  to  be  broken  up.  Wavy  breathing,  when  general,  has  no  special 
significance,  and  when  localised  it  may  depend  on  various  other  conditions 
besides  tubercle. 

From  the  deficient  entry  of  air  to  the  affected  part  of  the  lung,  there 
may  be  enfeeblement  of  the  breath  sounds,  but  the  existence  of  consolidation 
often  generally  leads  to  a  harsh  or  bronchial  quality.  The  earliest  physical 
sign  which  is  really  characteristic,  is  the  presence  of  rales  or  crepitations. 
At  first,  crepitations  may  be  only  occasionally  heard,  perhaps  only  during 
the  inspirations  immediately  following  cough.  Such  crepitations  resemble 
fine  crackles.  Care  must  be  taken  not  to  mistake  for  crepitations  sounds 
produced  in  the  oesophagus  by  the  patient  swallowing  after  coughing.  This 
error  can  be  avoided  by  telling  the  patient  not  to  swallow  after  the  cough, 
or  by  requesting  him  to  keep  his  mouth  open,  when  swallowing  becomes 
impossible. 

Comparative  dulness  at  one  or  other  apex  is  often  an  early  physical 
sign,  sometimes  preceding  crepitation.  Taken  in  connection  with  other 
signs,  even  slight  loss  of  resonance  has  great  importance.  It  must  be  borne 
in  mind,  however,  that  even  in  health  there  is  a  slight  difference  between  the 
percussion  notes  at  the  two  apices,  there  often  being  a  little  less  resonance 
at  the  right  than  that  at  the  left  apex.  Dulness  results  from  consolidation 
of  lung  and  to  some  extent  when  there  is  much  thickening  of  the  pleura. 
In  cases  where  the  consolidation  is  extensive,  the  dulness  will  be  so  also. 
When  the  general  health  is  good,  and  there  is  no  evidence  of  active  disease, 
marked  dulness  generally  points  to  fibrosis  of  the  lung. 

When  a  portion  of  lung  is  consolidated,  and  the  tubes  leading  to  and 
permeating  it  are  patent,  the  breath  sounds  acquire  a  bronchial  or  tubular 
character.  The  patent  tubes  surrounded  by  solid  lung  conduct  the  breath 
sounds  from  the  larger  tubes  with  great  distinctness,  and  as  no  air  enters 
the  affected  part,  the  vesicular  character  of  the  breath  sounds  ordinarily 
audible  over  it  is  completely  lost.  If,  however,  there  is  much  thickening  of 
pleura  and  narrowing  or  blocking  of  the  tubes  in  the  consolidated  part  of 
the  lung,  the  breath  sounds,  instead  of  being  tubular,  may  be  enfeebled  or 
almost  absent.  The  changes  in  the  breath  sounds  which  occur  on  the 
formation  of  a  cavity  will  be  considered  later.  When  the  breath  sounds 
are  bronchial,  pectoriloquy  will  be  audible.  Pectoriloquy,  indeed,  may 
often  be  heard  before  bronchial  breathing.  It  is  less  easily  missed  than 
bronchial  breathing,  and  its  presence  at  a  particular  spot  may  lead  to  the 
detection  of  other  signs  previously  overlooked.  The  vocal  fremitus  and 
resonance  are  increased  over  consolidated  areas,  except  when  there  is  much 
thickening  of  the  pleura  or  blocking  of  the  tubes. 

When  there  is  consolidation,  and  the  tubes  connected  with  the  con- 


4i 5  GENERAL  DISEASES. 

solidated  areas  are  patent,  any  crepitations  produced  will  be  conducted  to 
the  ear  with  increased  distinctness,  for  the  same  reason  that  the  breath 
sounds  are  bronchiaL  Such  crepitations  are  sometimes  spoken  of  as  "  con- 
sonating,"  and  have  a  peculiar  bright  or  clear  quality. 

The  most  conclusive  sign  of  softening  is  the  discovery  of  elastic  tissue 
in  the  sputa.  Coarse  and  very  abundant  rales  with  a  metallic  quality, 
succeeding  rales  of  a  dry  or  finely  crackling  quality,  are  generally  regarded 
as  characteristic  of  softening  and  cavity  formation.  No  doubt  in  the  great 
majority  of  cases  it  is  so,  but  in  exceptional  cases  such  sounds  may  depend 
on  other  causes. 

Where  a  portion  of  the  lung  is  consolidated  and  air  does  not  enter  it, 
the  corresponding  part  of  the  chest  wall  is  comparatively  motionless.  A 
diminution  or  absence  of  movement  of  the  region  above  or  below  the 
clavicle  is  very  significant,  and  often  at  once  attracts  attention  to  the 
affected  part.  When  pleurisy  is  a  complication,  friction  or  the  usual  signs 
of  pleural  effusion  will  be  present. 

The  signs  of  a  cavity. — It  often  happens  that  a  cavity  may  be  present 
and  yet  not  give  rise  to  characteristic  signs.  It  may  be  deeply  situated,  or 
it  may  be  surrounded  by  thickened  pleura,  fibrous  tissue,  or  consolidated 
lung,  or  it  may  be  filled  with  secretion,  and  so  the  ordinary  signs  may  be 
modified.  Moreover,  the  cavity  must  have  attained  a  certain  magnitude 
before  its  signs  become  well  marked.  The  most  characteristic  physical 
signs  of  .a  cavity  result  from  the  vibration  of  the  air  in  its  interior  in  a 
definite  way,  depending  on  its  shape  and  size.  Both  the  percussion  note 
and  the  sounds  produced  inside  the  cavity  take  on  a  peculiar  quality,  due 
to  this  cause.  The  pitch  of  the  percussion  note  varies  with  the  size  of  the 
cavity,  being  high  when  the  cavity  is  small,  and  relatively  low  when  it  is 
large.  The  peculiar  cavernous  quality  of  the  percussion  note  is  always 
better  elicited  when  the  patient  keeps  his  mouth  open  during  the  percus- 
sion. The  more  superficial  the  cavity,  the  more  distinctly  is  this  quality 
obtained.  The  note  may  then  be  spoken  of  as  the  cavernous  percussion 
note.  When  a  cavity  is  filled  with  secretion,  the  percussion  note  is  simply 
dull 

The  percussion  note  over  a  cavity  sometimes  possesses  another  peculiar 
quality,  the  well-known  cracked  pot  sound  or  bruit  de  pot  feU.  It  is 
advisable  for  its  production  that  the  percussion  stroke  should  be  rather 
sudden,  but  not  necessarily  forcible,  and  that  the  patient  should  keep  his 
mouth  open.  In  children  the  pot  feU  sound  has  sometimes  no  significance, 
and  may  be  produced  without  there  being  any  pathological  condition.  The 
breath  sounds  audible  over  a  cavity  are  frequently  as  characteristic  as  the 
percussion.  They  are  bronchial  or  tubular,  with  the  important  addition  of 
a  peculiar  blowing  quality  due  to  resonance  in  the  cavity.  They  become 
possessed  of  the  qualities  of  the  cavity  note.  These  breath  sounds  are 
spoken  of  as  cavernous  or  amphoric.  It  has  been  pointed  out  that  the 
expiratory  sound  is  often  of  a  lower  pitch  than  the  inspiratory.  Crepita- 
tions as  well  as  voice  and  cough  sounds  audible  over  a  cavity  are  often 
possessed  of  a  similar  metallic  or  hollow  quality. 

»  Mention  should  also  be  made  of  what  has  been  called  the  post-tussive 
suction  sound.  After  the  patient  coughs,  in  which  act  a  certain  amount  of 
air  may  be  expelled  from  the  cavity,  the  air  may  be  heard  to  return  with  a 
peculiar  sucking  or  hissing  sound,  as  it  does  when  an  indiarubber  ball 
with  a  hole  in  it  is  compressed  and  suddenly  allowed  to  expand.  The 
presence  of  this  sound,  though  characteristic,  is  exceptional. 


TUBERCULOSIS. 


4i7 


We  have  referred  to  the  impairment  or  loss  of  movement  of  the  chest 
wall  observed  in  consolidation  of  the  lung.  This  is  equally  the  case  when 
there  is  a  contracting  excavation  of  the  lung,  in  which  case  the  chest 
wall  often  becomes  flattened,  and  a  hollow  may  form  above  or  below 
the  clavicle.  The  most  striking  changes  occur  when  there  is  extensive 
loss  of  substance  and  contraction  of  the  lung  as  the  result  of  excavation 
or  fibrosis.  When  such  contraction  occurs  in  the  left  lung,  the  heart  is 
uncovered  and  drawn  over  further  to  the  left,  and  its  pulsations  may 
be  seen  in  the  second  and  third  interspaces,  while  the  impulse  may  be 
visible  as  far  to  the  left  as  the  anterior  axillary  line  or  even  further  out. 
When  the  disease  exists  in  the  right  lung,  then  there  may  be  drawing 
over  of  the  heart  to  the  right,  and  pulsation  of  the  aorta  may  be  distinctly 
visible  in  the  second  right  interspace.  In  these  cases  the  opposite  lung  is 
generally  over  expanded,  and  reaches  for  some  distance  across  the  middle 
line. 

The  course  of  chronic  pulmonary  tuberculosis  may  be  extremely  pro- 
tracted. The  disease  may  be  arrested  at  one  or  other  stage,  and  no  further 
change  occur  for  years.  In  many  cases  arrest  is  only  temporary.  After 
an  interval  the  disease  once  more  becomes  active,  possibly  to  be  again 
arrested  later  on.  The  extension  of  the  disease  to  the  larynx  or  intestine, 
or  the  outbreak  of  general  tuberculosis,  will  bring  the  case  to  a  more  rapid 
termination  than  otherwise.  Haemoptysis  and  pneumothorax  may  com- 
plicate the  case  at  any  time,  and  prove  the  direct  cause  of  death.  Haemo- 
ptysis has  already  been  discussed  at  some  length.  It  remains  to  say  a  few 
words  regarding  pneumothorax 

Pneumothorax,  as  has  been  said,  is  a  complication  which  may  occur  at 
almost  any  stage  in  the  disease.  It  is  not  likely,  however,  to  happen  unless 
the  morbid  process  is  active.  Its  most  usual  cause  is  the  undermining  of 
the  pleura  by  a  small  superficial  patch  of  tuberculous  softening. 

Its  onset  is  generally  accompanied  by  pain  in  the  side,  dyspnoea,  and 
more  or  less  collapse.  On  examination,  the  affected  side  is  found  to  move 
little  and  to  be  over-resonant  the  breath  sounds  are  feeble,  and  possibly 
metallic  and  cavernous  in  character,  while  adventitious  sounds  acquire  the 
same  metallic  quality.  There  is  displacement  of  organs  to  the  sound  side, 
away  from  the  pneumothorax.  A  very  characteristic  sign  is  the  bruit 
cVairain,  the  bell  sound  audible  over  a  pneumothorax  on  auscultation 
while  percussion  is  made  with  two  coins,  one  being  used  as  pleximeter,  the 
other  as  plexor.  The  pathognomonic  succussion  splash,  for  the  eliciting 
of  which  there  must  be  fluid  as  well  as  air  in  the  pleura,  requires  that  the 
ear  or  stethoscope  should  be  applied  to  the  chest  while  the  patient  is 
shaken  or  shakes  himself.  An  occasional  difficulty  in  diagnosis  is  to 
distinguish  a  large  cavity  from  a  pneumothorax.  The  direction  of  the 
displacement  of  organs  is  a  very  important  element  in  the  diagnosis,  the 
displacement  being  towards  a  cavity,  but  away  from  a  pneumothorax. 
The  bruit  d'airain,  when  present,  points  to  pneumothorax  rather  than  to 
pulmonary  excavation. 

Prognosis. — The  prognosis  in  chronic  pulmonary  tuberculosis  is 
often  a  matter  of  the  highest  difficulty.  Some  patients  exhibit  a  surprising 
recuperative  power,  some  suddenly  and  rapidly  go  down-hill,  and  others 
are  unexpectedly  carried  off  by  fatal  haemoptysis,  pneumothorax,  or  general 
tuberculosis.  Whenever  there  is  evidence  of  great  activity  of  the  disease, 
as  shown  by  rapid  loss  of  flesh  and  strength,  profuse  sweating,  high  tempera- 
tures, rapid  cardiac  action,  diarrhoea,  etc.,  the  prognosis  is  very  grave.  The 
vol.  1. — 27 


4i 8  GENERAL  DISEASES. 

complication  with  laryngeal  tuberculosis  is  always  very  unfavourable,  with 
the  reservations  already  alluded  to. 

It  must  be  clearly  borne  in  mind  that  more  depends  on  the  general 
condition  of  the  patient  than  on  the  extent  or  stage  of  the  disease  in  the 
lungs  as  revealed  by  physical  examination.  The  student,  and  indeed  the 
practitioner,  is  apt  to  think  that  prognosis  is  chiefly  influenced  by  the 
stage  which  the  disease  has  reached  in  the  lung.  A  patient  in  the  third 
stage  is  accordingly  thought  to  be  worse  than  one  in  the  second  stage,  and 
much  worse  than  one  in  the  first.  Such  an  idea  is  an  entirely  erroneous 
one.  In  whatever  stage  the  disease  in  the  lung  exists,  provided  the  state 
of  nutrition  is  good,  the  pulse  quiet,  the  temperature  normal,  the  tongue 
clean,  the  appetite  hearty,  and  the  bowels  regular,  the  prognosis  will  be 
favourable,  the  more  so,  of  course,  the  less  the  amount  of  the  damage  to 
the  lungs.  Where  the  reverse  conditions  prevail,  the  prognosis  will  be 
correspondingly  unfavourable.  "We  shall  consider,  separately,  a  number  of 
side  issues  which  affect  our  prognosis. 

Age. — The  time  of  life  at  which  the  disease  exhibits  greatest  activity  is 
between  the  ages  18  and  30.  The  existence  of  the  active  disease  at  this 
period  will  always  excite  a  fear  of  rapid  progress.  In  children  the  disease 
sometimes  becomes  very  chronic,  although  usually  rapid.  In  elderly  people, 
or,  it  may  be  said,  over  the  age  of  45,  the  disease  is  often  only  very  slowly 
progressive. 

Sex. — Women,  on  the  whole,  exhibit  less  resistance  to  the  disease  than 
men,  and  are  attacked  at  a  rather  earlier  age.  Child-bearing  has  a  very 
unfavourable  influence  on  the  course  of  the  disease. 

Heredity. — Cases  in  which  there  is  a  family  history  of  phthisis,  on  the 
whole,  do  worse  than  those  in  which  there  is  none,  and  one  may  be  guided 
in  prognosis  by  the  type  which  the  disease  has  assumed  in  other  members 
of  the  family,  especially  in  brothers  or  sisters.  If  the  disease  has  been 
rapidly  progressive,  or  has  run  a  favourable  course  in  the  collaterals,  it  will 
probably  be  so  in  the  patient.  J.  E.  Pollock  has  instanced  a  case  where 
nineteen  members  of  a  family  of  twenty-two  died  at  the  age  of  19. 

Constitution  and  habits. — It  goes  without  saying  that  if  the  patient 
comes  of  a  healthy  stock,  is  of  good  physique,  and  has  previously  exhibited 
a  sound  constitution,  he  is  more  likely  to  do  well  than  a  man  with  bad 
family  history,  of  poor  physique,  and  previously  weakly,  and  a  history  of 
bronchitis,  pleurisy,  or  pneumonia.  The  man  who  has  been  intemperate, 
or  has  led  a  life  of  debauchery,  will  be  less  resistant  to  the  progress  of  the 
disease  than  he  who  has  proved  himself  temperate  in  all  things. 

Environment. — The  circumstances  of  the  patient  have  much  to  do  with 
the  prognosis.  The  possession  of  affluent  means  commands  many  of  the 
elements  most  advantageous  for  favourably  influencing  the  progress  of  the 
malady,  such  as  good  food,  hygienic  surroundings,  and  residence  in  a  suitable 
climate,  with  possibilities  of  abundant  sunshine  and  fresh  air.  Straitened 
circumstances,  on  the  other  hand,  put  such  important  remedial  agencies  out 
of  the  patient's  reach.  This  is  well  shown  by  the  different  estimates  of  the 
duration  of  life  among  the  well-to-do  and  the  lower  classes.  C.  T.  Williams 
gives  seven  years  and  eight  months  as  the  average  duration,  among  198 
•  cases  occurring  in  private  practice  followed  to  a  fatal  termination.  J.  E. 
Pollock  gives  an  average  duration  of  nineteen  months  for  males,  and  twenty- 
two  months  for  females,  founded  on  828  hospital  cases. 

Bate  of  progress. — It  has  been  already  mentioned  how  unfavourable  is 
the  prognosis  in  the  acute  pneumonic  type.     Great  activity  and  swift  pro- 


TUBERCULOSIS.  419 

gress,  shown  by  rapidly  spreading  consolidation,  or  the  quick  formation  of 
cavities,  or  extension  of  those  already  formed,  are  always  of  grave  omen. 
Slow  progress  of  disease,  as  shown  by  the  stationary  character  of  the 
physical  signs  and  their  limitation  to  the  part  in  which  they  were  originally 
situated,  is  good. 

Extent  and  stage  of  disease. — The  limitation  of  the  disease  to  a  single 
lung,  and  to  the  upper  part  of  that,  is  favourable.  Evidence  of  induration 
and  fibrosis  is  good.  Thus  flattening  of  the  side  and  intense  wooden 
dulness,  along  with  good  general  condition,  indicate  very  chronic  non- 
advancing  disease.  On  the  other  hand,  diffusion  of  disease  through  both 
lungs  and  the  absence  of  evidence  of  induration  are  unfavourable.  The 
cessation  of  rales  and  retraction  of  the  chest  wall,  where  previously  rales 
have  been  abundant,  is  favourable. 

Expectoration. — Profuse  expectoration  is  a  bad  sign.  The  diminu- 
tion of  amount  is  good.  When  the  expectoration  consists  only  of  a  small 
amount  of  tenacious  mucus,  it  is  favourable.  The  presence  of  elastic  fibres 
in  the  sputum  shows  that  destruction  of  lung  tissue  is  still  going  on. 

Bacilli  in  the  sputum. — Great  abundance  of  bacilli,  on  repeated  ex- 
amination, is  a  bad  sign.  The  disappearance  of  the  bacilli  in  a  case  where 
they  were  formerly  abundant  is  very  favourable,  provided  this  is  accom- 
panied by  improvement  in  the  patient.  Not  much  help  in  prognosis  is 
afforded  by  a  frequent  examination  of  the  sputum  for  bacilli. 

Pyrexia. — High  and  continued  fever  is  always  a  bad  sign.  Although 
normal  or  nearly  normal  temperature  is  generally  favourable,  and  points, 
as  a  rule,  to  quiescence  of  disease,  patients  sometimes  go  steadily  down-hill 
without  much  rise  of  temperature. 

Bronchitis. — The  coexistence  of  bronchitis  with  phthisis  is  unfavourable. 
It  creates  a  suspicion  that  the  disease  has  become  disseminated  throughout 
the  lungs. 

Pneumonia  is  an  anxious  complication  and  often  proves  fatal,  but  it  may 
be  perfectly  recovered  from. 

Haemoptysis. — Cases  in  which  haemoptysis  occurs  early  in  the  disease 
often  run  a  very  favourable  course.  Cases  in  which  haemoptysis  is  frequently 
repeated  do  not,  as  a  rule,  do  well.  Haemoptysis  in  the  later  stages  is 
generally  unfavourable. 

Pneumothorax.  —  The  most  favourable  statistics  give  the  general 
mortality  of  pneumothorax  as  70  per  cent.  The  risk  to  life  is  greatest 
during  the  early  period,  and  as  a  rule  this  complication  is  followed  by 
death  in  a  short  time,  if  it  affects,  as  it  frequently  does,  the  less  diseased 
side.  When  there  is  little  disease  on  the  side  opposite  to  the  pneumo- 
thorax, the  patient  may  do  well.  I  have  known  a  patient  to  recover  from 
two  attacks  of  pneumothorax,  one  on  each  side,  as  happened  in  a  case 
recorded  by  Samuel  West.  Magee  Finny  has  recorded  a  case  of  recovery 
after  recurrence  of  pneumothorax  on  the  same  side.  The  cases  which  do 
best  are  those  in  which  no  effusion  occurs. 

Digestive  system. — The  appetite  and  digestion  form  an  excellent  index 
as  to  the  general  condition  of  the  patient.  It  is  a  good  sign  when  the 
tongue  is  clean,  the  appetite  good,  and  powers  of  digestion  unimpaired.  A 
furred  tongue,  with  persistent  anorexia  and  feeble  digestion,  is  a  bad  sign, 
unless  a  better  condition  of  things  can  be  brought  about  by  means  of 
treatment.  Diarrhoea  occurring  in  an  advanced  stage  of  the  disease  is 
usually  an  ominous  sign,  especially  when  it  is  not  amenable  to  treatment. 
Peritonitis  usually  proves  rapidly  fatal. 


42 o  GENERAL  DISEASES. 

Nervous  system. — The  existence  of  a  condition  of  morbid  erethism  and 
general  excitability  is  unfavourable.  Those  of  a  phlegmatic  and  stable 
temperament  are  likely  to  do  better  than  the  nighty  and  highly  strung. 
The  excitable  person  readily  becomes  feverish,  sleeps  badly,  and  exhibits  a 
restlessness  of  mind  and  body  which  have  a  bad  general  effect.  The 
occurrence  of  insanity  or  evidence  of  cerebral  tubercle  is  highly  unfavour- 
able. 

Prophylaxis. — The  prophylaxis  of  pulmonary  tuberculosis  is  one 
of  the  most  important  questions  of  the  present  day.  On  the  one  hand, 
there  are  some  who  take  an  extreme  view  and  regard  every  case  as 
dangerously  infectious,  demanding  compulsory  notification,  disinfection, 
isolation,  and  periodical  inspection.  On  the  other  hand,  there  are  men 
of  large  experience  who,  while  admitting  the  possibility  of  infection,  are 
not  of  opinion  that  there  is  much  to  be  feared  from  it.  I  have  been 
careful  at  the  outset  to  point  out  that  while  the  disease  is  always  the 
result  of  infection,  it  is  not  always  infectious.  Many  of  the  local  forms 
of  tuberculosis  as  well  as  cases  of  acute  miliary  tubercle  are,  as  a  rule, 
non-infectious.     In  them  there  is  no  discharge  of  bacilli  outside  the  body. 

The  disease  is  only  infectious  when,  first,  there  is  some  external  dis- 
charge of  tuberculous  matter ;  and,  second,  this  discharge  contaminates 
food  or  drink,  or  is  allowed  to  become  dry  and  in  the  form  of  dust  con- 
taminates the  air.  One  important  branch  of  prophylaxis  consists  in  the 
disposal  of  the  sputum  and  the  prevention  of  it  from  becoming  dry  or 
contaminating  food  or  drink. 

The  tuberculous  patient  who  expectorates,  unless  he  follows  simple 
rules  to  be  presently  specified,  is  a  common  danger  to  the  community.  The 
tuberculous  patient  who  swallows  his  expectoration  is  reinfecting  himself, 
but  is  for  the  time  being  non-infectious  to  the  community.  The  faeces  of  a 
tuberculous  patient  may  be  infectious  if  he  is  swallowing  his  expectoration, 
or  if  he  has  ulceration  of  the  intestines,  but  the  chances  of  their  becoming 
dry  or  contaminating  food  or  drink  are  very  small. 

Much  can  be  done  towards  the  prevention  of  tuberculosis,  by  educating 
the  masses  as  to  the  proper  means  of  disposing  of  the  expectoration. 
For  the  protection  of  their  own  families,  and  to  prevent  the  spread  of  the 
disease  among  the  general  public,  consumptive  persons  should  act  on  the  fol- 
lowing simple  rules,  which  have  been  drawn  up  by  the  National  Association 
for  the  prevention  of  consumption.  "  The  consumptive  person  must  not  ex- 
pectorate about  the  house,  nor  on  the  floor  of  any  cab,  omnibus,  tram-car, 
railway  carriage,  or  other  conveyance.  Spitting  about  the  streets,  or  in 
any  public  buildings  (churches,  schools,  theatres,  railway  stations,  etc.),  is  a 
dangerous  as  well  as  a  filthy  habit.  The  consumptive  person  must  not 
expectorate  anywhere  except  into  a  special  vessel  or  cup  kept  for  the 
purpose,  and  containing  a  little  water.  When  out  of  doors,  a  small,  wide- 
mouthed  bottle  with  a  well-fitting  cork  may  be  used ;  or  a  pocket  spittoon, 
which  may  be  obtained  from  any  chemist.  For  wiping  the  mouth,  a  rag 
or  paper,  which  can  afterwards  be  burnt,  should  be  used  instead  of  a  hand- 
kerchief. The  collected  expectoration  must  be  carefully  burnt  on  the 
back  of  the  fire,  at  least  once  daily ;  this  is  the  simplest,  quickest,  and 
safest  way  of  destroying  the  germ.  When  there  is  no  fire,  the  expectora- 
tion must  be  washed  into  the  drain  or  buried  in  the  earth.  The  cup  or 
spittoon  must  then  be  well  washed  with  boiling  water.  When  not  pro- 
vided with  a  proper  vessel,  a  consumptive  person  must  not  spit  into  a 
handkerchief,  but  into  a  piece  of  rag  or  paper,  which  must  be  burnt. 


TUBERCULOSIS.  421 

Consumptive  persons  must  not  swallow  their  expectoration,  as  by  eo 
doing  the  disease  may  be  conveyed  to  parts  of  the  body  not  already 
affected.  A  consumptive  person  must  not  kiss,  or  be  kissed,  on  the 
mouth."  Notices  forbidding  spitting  should  be  put  up  in  workrooms, 
public  buildings,  railway  stations,  and  conveyances.  A  tuberculous  person 
should  not  act  as  wet  nurse,  and  should  not  be  employed  as  cook,  nurse- 
maid, or  attendant  on  healthy  persons.  It  is  always  advisable  that  a 
tuberculous  subject  should  sleep  alone,  and  if  possible  have  a  separate  room. 
All  rooms  inhabited  by  consumptive  persons  ought  to  have  an  especially 
large  amount  of  sunlight,  or  at  least  daylight,  and  be  efficiently  venti- 
lated and  kept  thoroughly  clean,  being  cleansed  with  wet,  not  dry,  dusters 
and  brooms,  so  as  to  avoid  accumulation  of  dust,  and  to  prevent  du^t 
flying  about  in  the  ah'  of  the  room. 

"When  a  patient  becomes  confined  to  bed,  the  greatest  cleanliness  is 
necessary,  and  every  care  should  be  taken  to  avoid  the  soiling  of  the 
linen  with  expectoration  or  faeces.  The  sheets  should  be  frequently 
changed,  and  these  and  the  bedding  treated  in  the  same  way  as  in  a  case 
of  enteric  fever.  Every  room  or  house  in  which  a  consumptive  person 
has  lived  or  died  should  be  thoroughly  cleansed,  or,  still  better,  disinfected 
before  it  is  again  inhabited. 

At  the  present  time  there  is  a  lamentable  want  of  provision  for 
advanced  cases  of  phthisis  among  the  working  and  poorer  classes. 
Hospitals  will  not  take  them  in.  The  refuge  of  the  workhouse  infirmary 
is  often  refused  by  them.  The  husband  or  wife,  as  the  case  may  be,  and 
perhaps  a  family  of  small  children,  share  the  sick  person's  room  until 
death  ends  the  scene.  These  are  the  cases  which  are  most  likely  to 
propagate  the  disease.  A  sufficient  number  of  properly  equipped  hospitals 
for  cases  of  advanced  phthisis  is  urgently  needed  in  all  large  centres  of 
population. 

We  have  stated  elsewhere  what  we  believe  undoubtedly  to  be  the  case, 
that  the  principal  mode  of  infection  is  from  man  to  man,  and  we  consider 
that  it  is  in  this  direction  that  the  greatest  good  can  be  done.  Infection 
from  the  lower  animals  to  man  is  another  mode  which  must  be  borne  in 
mind.  We  have  pointed  out  the  enormous  prevalence  of  tuberculosis 
among  cattle  and  the  dangers  arising  from  infected  milk  or  meat,  and 
shown  how  this  danger  can  be  removed  by  boiling  the  milk  and 
thoroughly  cooking  the  meat. 

The  prevention  of  tuberculosis  among  cattle  may  be  best  attained  by 
attention  to  the  hygiene  of  the  cowsheds  and  by  periodical  testing  by 
means  of  tuberculin,  and  the  complete  separation  of  all  animals  found  to 
be  infected  from  those  which  are  free  from  tubercle.  The  calves  of  tuber- 
culous cows  should  be  separated  from  their  mothers  and  brought  up  on  the 
milk  of  healthy  animals.  ISTo  infected  animal  should  on  any  account  be 
permitted  to  remain  in  a  dairy. 

As  regards  the  person  who  is  non-tuberculous,  he  will  best  escape 
infection  by  leading  a  healthy  life,  by  living  soberly  and  simply,  by  keeping 
his  muscles  in  tone  by  exercise,  his  blood  properly  oxygenated  by  fresh 
air,  and  his  skin  in  good  condition  by  baths,  and  by  seeing  that  his  dwell- 
ing is  clean  and  well  ventilated. 

Marriage. — The  physician  will  never  sanction  marriage  in  a  case  where 
there  is  evidence  of  active  tuberculous  disease.  He  will  often  be  consulted 
as  to  the  advisability  of  marriage  in  a  case  where  the  disease  is  arrested. 
The  important  points  are,  first,  the  effect  of  married  life  on  the  patient's 


422  GENERAL  DISEASES. 

own  health ;  second,  the  risk  of  infecting  the  spouse ;  and,  third,  the  pre- 
disposition to  tubercle  of  the  children,  if  any.  No  doubt  the  safest  rule  to 
lay  down  is,  that  no  one  who  shows  or  has  shown  signs  of  pulmonary 
tuberculosis  should  marry.  This  rule  is  one  which  patients  will  not  follow, 
unless  it  suits  them  to  do  so.  On  the  health  of  the  man  who  is  temperate 
in  all  things,  and  is  possessed  of  sufficient  means  to  support  a  wife  in 
comfort,  marriage  can  have  no  deteriorating  effect.  In  the  case  of  the 
woman  it  is  different.  The  risk  of  child-bearing  is  one  which  has  already 
been  referred  to.  Pregnancy  and  parturition,  especially  when  repeated, 
are  likely  to  have  an  unfavourable  effect  on  the  course  of  pulmonary 
tuberculosis,  and  quicken  arrested  disease  into  renewed  activity.  With 
regard  to  the  second  point,  if  the  disease  is  really  arrested,  there  is,  for  the 
time,  no  risk  of  infection.  Even  in  the  case  where  there  is  expectoration 
containing  bacilli,  proper  precautions  as  to  its  disposal  should  prevent 
infection ;  but  it  is  always  advisable  in  such  cases  that  the  husband  and 
wife  should  occupy  separate  beds.  The  third  question,  as  to  the  effect  on 
the  issue  of  the  marriage,  is  a  very  important  one.  There  is  much  evidence 
to  show  that  the  children  of  a  tuberculous  parent  offer  less  resistance  to 
bacillary  infection  than  the  children  of  non-tuberculous  parents.  We 
believe  that  they  require  special  care  and  watchfulness,  but  that  with  these 
and  a  healthy  environment  they  are  likely  to  grow  up  as  strong  as  other 
children. 

Treatment. — The  treatment  of  pulmonary  tuberculosis  may  be  con- 
sidered under  various  aspects — medicinal,  dietetic,  hygienic,  and  climatic. 
These  again  may  be  discussed  as  they  concern  the  disease  itself  or  its  com- 
plications. 

We  propose  first  to  say  a  few  words  concerning  some  of  the  medicinal 
substances  which  have  been  found  by  experience  to  be  serviceable  and  to 
have  a  favourable  influence  on  the  course  of  the  disease.  We  shall  then 
consider  treatment  as  directed  to  the  relief  of  symptoms  and  complications. 
After  this,  we  shall  briefly  discuss  diet,  hygiene,  and  climate,  and  their 
uses  in  the  disease.  Finally,  we  shall  give  a  brief  summary  of  the 
attempts  which  have  been  made  to  treat  the  disease  from  the  bacterio- 
logical standpoint. 

Medicinal. — For  half  a  century  cod-liver  oil  has  been  highly  esteemed  as 
a  remedial  agent.  Under  its  use  gain  in  weight  and  strength  is  observed. 
The  researches  of  Heyerdahl  show  that  the  oil  is  not  a  simple  mixture  of 
olein,  palmitin,  and  stearin,  but  to  the  extent  of  40  per  cent,  contains  two 
glycerides  of  peculiar  fatty  acids  which  are  very  unstable  and  difficult  to 
isolate.  It  is  probably  to  the  presence  of  these  bodies  that  the  oil  owes  its 
effect,  and  it  is  useless  to  attempt  to  separate  something  from  the  oil 
which  could  be  used  as  a  substitute.  In  practice,  a  common  mistake  is  to 
prescribe  the  remedy  in  too  large  doses.  A  teaspoonful  twice  a  day  is 
generally  sufficient  at  first,  and  it  is  seldom  necessary  to  give  more  than 
twice  as  much  later  on.  The  best  time  of  administration  is  about  half  an 
hour  after  meals  or  at  bedtime.  The  oil  should  never  be  given  before  food. 
Patients  vary  extremely  in  their  ability  to  take  oil.  Some  can  take  large 
doses  without  the  least  inconvenience.  Others  are  nauseated  by  the  smallest 
quantity.  On  account  of  the  nauseating  properties  of  cod-liver  oil,  various 
modes  of  exhibiting  it  have  been  devised.  Of  these  the  most  palatable 
and  readily  tolerated  is  the  mixture  with  malt  extract.  From  25  to  35 
per  cent,  of  oil  is  present  in  the  ordinary  mixtures.  The  malt  extract  has 
a  slight  nutritive  value,  but  it  is  very  doubtful  whether  in  this  combination 


TUBERCULOSIS.  423 

its  starch-converting  power  is  of  much  importance.  Emulsions  contain 
about  the  same  proportion  of  oil,  perhaps  a  little  more.  Apart  from  the 
greater  ease  with  which  it  is  swallowed,  there  is  probably  not  so  much 
benefit  in  a  tablespoonful  of  emulsion  as  in  a  dessertspoonful  of  oil.  The 
oil  may  also  be  given  in  capsules,  and  in  some  cases  inunction  may  be 
usefully  employed.  Preparations  known  as  morrhuol  and  wine  of  cod-liver 
oil,  supposed  to  represent  active  principles  of  the  oil,  are  probably  of  little 
value.  The  light-brown  oil,  which  probably  contains  decomposition  pro- 
ducts, is  more  nauseous  and  less  easily  tolerated  by  the  stomach  than  the 
ordinary  oil.  Among  useful  substitutes  for  cod-liver  oil,  pancreatic  emulsion 
and  petroleum  emulsion  may  be  mentioned. 

Of  late  years,  creosote  has  been  very  extensively  employed.  It  is 
given  in  gradually  increasing  doses.  To  begin  with,  1  minim  three  times 
a  day  is  taken,  then  2  minims,  and  so  on,  until  doses  of  10  or  15 
minims  or  even  more  are  reached.  It  has  a  disagreeable  taste,  and  is  most 
readily  taken  in  capsules  containing  1  to  5  minims  each.  Milk  covers 
its  taste  fairly  well.  It  should  be  taken  after  food.  The  best  evidence  of 
its  good  effect  is  the  improvement  in  the  appetite  which  frequently  follows 
its  administration.  Cough  and  expectoration  are  often  favourably 
influenced.     It  has  no  specific  action,  however,  on  the  tuberculous  lesions. 

Still  more  recently  guaiacol  and  carbonate  of  guaiacol  have  been  intro- 
duced. Guaiacol,  which  is  one  of  the  principal  constituents  of  creosote,  is 
less  disagreeable  in  taste  than  the  latter,  while  the  carbonate  of  guaiacol  is 
quite  tasteless.  Both  are,  however,  much  more  expensive  than  creosote. 
Guaiacol  may  be  given  in  the  same  doses  as  creosote,  and  the  carbonate 
in  doses  of  from  5  to  15  grs.  Although  these  drugs  have  been  largely 
used  at  the  Brompton  Hospital,  it  has  not  been  made  out  that  they  have 
any  distinct  advantages  over  creosote,  except  that  of  palatability. 

Guaiacol  has  also  been  administered  hypodermically,  and  benefit  has 
been  reported  in  some  cases  from  its  use  in  this  way,  when  it  has 
failed  to  do  good  given  by  the  mouth.  To  begin  with,  a  minim  is 
injected,  and  if  this  is  well  borne,  the  amount  is  gradually  increased 
up  to  5  or  7  minims.  The  injections  are  usually  made  into  the 
buttock,  the  needle  being  inserted  deeply  at  right  angles  to  the  surface. 
The  epidermic  method  is  sometimes  employed,  the  cutaneous  area  corre- 
sponding to  the  pulmonary  lesion  being  painted  with  10  to  30  minims  of 
guaiacol.  Many  other  derivatives  of  creosote  have  been  used.  Among 
these  may  be  mentioned  creosote  carbonate  or  creosotal,  a  viscous  liquid, 
benzoate  of  guaiacol  or  benzosol  and  guaiacetin,  both  tasteless  crystalline 
powders,  eosote  or  valerianate  of  creosote,  and  geosote  or  valerianate  of 
guaiacol,  and  piperidine  guaiacolate.  These  may  all  be  given  in  capsules 
or  cachets  in  doses  of  5  to  30  grs.  or  minims,  under  the  same  conditions 
as  creosote  itself. 

Garlic,  as  recommended  by  Vivian  Poore,  seems  to  have  much  the 
same  effect  as  creosote.  We  may  give  either  the  syrupus  allii  (U.S.P.) 
in  doses  of  1  to  3  dims.,  or  cloves  of  garlic  chopped  up  and  mixed  with 
beef -tea,  or  powdered  garlic  in  capsules,  in  doses  of  3  to  10  grs.  An  almost 
insuperable  objection  to  garlic  is  the  odour  which  it  imparts  to  the  breath. 
Oil  of  cloves,  in  doses  of  5  to  30  minims  in  capsules  three  times  a  day, 
is  the  favourite  remedy  with  some  physicians.  It  has  also  been  admin- 
istered subcutaneously.  Ichthyol  has  hitherto  had  a  very  limited  use  on 
account  of  its  extremely  disagreeable  taste  and  odour,  but  those  who  have 
succeeded  in  getting  patients  to  take  it  speak  well  of  the  results.    The  best 


424  GENERAL  DISEASES. 

mode  of  administration  is  in  the  form  of  capsules,  with  a  covering  such  as 
keratin,  which  will  not  dissolve  until  the  intestine  is  reached.  The  dose 
of  the  remedy  is  20  to  60  grs.  a  day. 

Nuclein  or  nucleinic  acid,  prepared  from  yeast,  has  been  employed  of 
late  years.  A  1  per  cent,  solution  of  nucleinic  acid  is  administered 
hypodermically  daily,  in  doses  of  from  60  to  80  minims.  Some  employ  a 
5  per  cent,  solution  in  doses  of  50  minims.  The  remedy  has  also  been 
given  by  the  mouth,  generally  in  association  with  injections.  Those  who 
have  used  it  most  largely  speak  well  of  its  effects.  Arsenic  is  often  highly 
beneficial  when  there  is  anaemia,  and  2  to  5  minims  of  Fowler's  solution 
may  be  given  in  combination  with  other  remedies  after  meals.  Hypo- 
phosphites  of  lime  and  soda  are  sometimes  useful  as  tonics,  in  doses  of  5  to 
10  grs.  They  have  no  specific  action,  and  their  beneficial  effects  in  the 
treatment  of  phthisis  have  been  greatly  exaggerated.  Other  hypophos- 
phites  used  are  those  of  iron,  manganese,  potash,  quinine,  and  strychnine. 
Iron  is  valuable  when  chlorosis  is  combined  with  phthisis,  but  in  ordinary 
cases  iron  is  not  very  well  borne,  and  it  should  be  avoided  when  there  is  a 
tendency  to  haemoptysis. 

External  applications. — Counter-irritation  has  always  been  a  favourite 
mode  of  treatment.  Eubefacients,  such  as  lin.  camph.  amnion,  or  lin.  tereb. 
acet.,  are  useful  when  there  is  bronchial  catarrh.  A  mustard  leaf  or  iodine 
paint  may  be  applied  over  the  apices  in  the  stage  of  infiltration.  Some- 
times a  more  powerful  counter-irritant,  the  lin.  crotonis,  is  employed,  but 
it  has  the  disadvantage  of  leaving  scars  which  are  often  permanent. 
When  there  is  pleurisy,  whether  dry  or  with  effusion,  relief  may  often  be 
afforded  by  strapping,  poulticing,  or  applications  of  belladonna. 

Food..— It  is  unnecessary  to  say  that  the  food  should  be  simple,  well 
cooked,  and  nutritious.  Not  only  is  there  often  almost  complete  loss  of 
appetite,  but  most  unsuitable  articles  of  diet  are  consumed.  The  loss  of 
appetite  is  associated  with  dyspepsia,  which  must  be  treated  on  the  lines 
already  laid  down.  The  simple  tonic  will  often  cure  the  dyspepsia,  and 
restore  the  appetite.  Bracing  air  often  works  wonders  in  restoring  the 
appetite.  Where  the  quantity  of  food  taken  is  obviously  too  little,  it  must 
be  judiciously  supplemented  by  milk,  butter,  eggs,  etc.  It  is  often  easy  to 
secure  that  the  patient  takes  two  or  three  pints  of  milk,  two  or  three 
ounces  of  butter,  and  two  or  three  eggs,  in  addition  to  the  food  previously 
taken.  Such  unsuitable  articles  of  diet  as  pickles,  ices,  nuts,  and  sweet- 
meats should  be  prohibited.  Judicious  feeding  forms  a  chief  part  of  the 
treatment  at  all  sanatoria  for  consumption. 

Koumiss,  or  fermented  mare's  milk,  has  been  highly  esteemed  as  a  food 
for  the  tuberculous.  This  is  prepared  in  the  steppes  of  the  Kirghiz,  in 
Southern  Eussia,  where  there  are  establishments  for  carrying  out  the  cure. 
The  beneficial  effects  which  have  been  observed  are,  no  doubt,  largely 
aided  by  the  climate.  Kefir,  or  fermented  cow's  milk,  is  used  in  the 
Caucasus.  The  so-called  koumiss  to  be  obtained  in  this  country  is  also 
fermented  cow's  milk,  artificially  sweetened.  Many  dislike  the  rather 
acidulous  taste  of  fermented  milk,  but,  for  those  who  will  take  it,  it  is  an 
excellent  combination  of  food  and  stimulant. 

Rest  and  exercise. — When  continuous  fever  is  present,  absolute  rest 
is  essential.  When  there  are  markedly  remittent  temperatures,  rest 
should  still  be  enforced.  When  the  temperature  rises  only  a  degree  or  so 
in  the  evening,  exercise  may  be  cautiously  prescribed.  Whenever  short- 
ness of  breath  on  exertion  is  at  all  a  marked  symptom,  I  am  very  strongly 


TUBERCULOSIS.  425 

of  opinion  that  as  little  strain  as  possible  should  be  put  on  the  breathing 
powers.  In  such  cases  I  1  egard  violent  exercise — as  tobogganing,  climbing, 
skating — as  dangerous  and  injurious.  Whatever  walking  exercise  is  taken 
should  be  taken  on  the  flat.  The  patient  should  always  use  the  lift  to  go 
upstairs,  if  one  is  available. 

If  with  moderate  exertion  there  is  no  shortness  of  breath,  then  not 
only  can  it  do  no  harm,  but  the  patient  will  be  better  for  it.  The  kind 
and  amount  of  exercise  may  be  determined  by  the  effect  on  the  patient's 
temperature.  If  there  is  a  rise  amounting  to  more  than  one  or  two 
degrees  after  exercise,  the  amount  must  be  reduced. 

Great  importance  has  been  attached  by  Brehmer  and  his  followers  to 
graduated  hill  climbing,  on  account  of  its  strengthening  effect  on  the 
heart.  The  walks  should  be  so  arranged  that  th&  patient  starts  with  a 
short  ascent,  then  has  a  walk  along  the  flat,  and  returns  home  down  hill. 
Walking  is  the  safest  form  of  exercise  until  the  disease  has  become  quiescent. 
Exercises  which  bring  into  action  the  muscles  of  respiration  are  very  use- 
ful. The  following  four  simple  exercises,  which  have  been  recommended 
by  Knopf,  are  given  as  illustrations.  In  the  first  exercise  the  patient 
stands  erect,  with  feet  together  and  hands  by  the  side.  The  arms  are  then 
slowly  raised  from  the  sides  until  they  are  horizontal,  the  patient  slowly 
inspiring.  After  a  brief  interval,  during  which  the  breath  is  held,  the 
arms  are  lowered  more  rapidly  during  expiration.  The  second  exercise 
is  a  modification  of  the  first,  the  movement  of  the  arms  being  continued 
until  the  hands  meet  over  the  head.  In  the  third  exercise  the  arms  are 
held  out  in  front,  palms  outwards,  and  slowly  brought  backwards  during 
inspiration  until  they  meet  behind  the  back.  The  movement  is  reversed 
during  expiration,  each  respiratory  act  being  followed  immediately  by  a 
secondary  forced  expiratory  effort.  In  the  fourth  exercise  the  patient 
stands  straight,  places  his  hands  on  his  hips,  with  thumbs  in  front,  and 
then  bends  slowly  backward  as  far  as  he  can  during  inspiration.  He 
holds  his  breath,  and  returns  to  original  position  during  expiration. 

Clothing,  etc. — Among  the  lower  classes,  through  fear  of  catching  cold, 
the  clothing  is  often  excessive.  Two  or  three  thick  woollen  vests  are 
worn,  and  the  undervest  is  probably  not  changed  at  night.  Woollen 
underclothing  should  be  worn  all  the  year  round — thin  in  the  summer,  and 
thick  in  the  winter.  The  clothing  should  be  sufficient  to  keep  the  patient 
warm,  but  not  too  heavy  to  interfere  with  exercise.  The  bedding  should 
be  carefully  adjusted  to  the  patient's  requirements.  A  thin  woollen  night- 
dress is  indicated  if  there  are  night  sweats.  The  bedroom  should  be  airy, 
well  ventilated,  and  scrupulously  clean.  There  should  be  no  hangings  or 
curtains  which  are  not  washable. 

Climate  and  fresh  air. — Of  all  influences  which  can  be  brought  to  bear 
on  pulmonary  tuberculosis,  none  can  be  compared  with  the  effects  of 
climate  and  fresh  air.  A  great  deal  may  be  done  by  altering  the  mode  of 
life,  by  securing  that  the  patient  occupies  well- ventilated,  airy  rooms,  and 
that,  as  far  as  practicable,  he  should  lead  an  out-of-door  life.  It  is  most 
important  to  teach  the  patient  to  have  the  windows  of  the  rooms  in 
which  he  lives  widely  open,  so  that  the  air  may  always  be  fresh. 
Wind,  rain,  snow,  fog,  want  of  sunshine,  and  sudden  changes  of  tem- 
perature are  the  great  trials  of  the  English  winter  climate.  These 
make  it  impossible  for  the  phthisical  patient  to  get  out  of  doors  on  many 
days  of  the  winter  months,  and  are  the  fruitful  cause  of  bronchial  catarrhs 
which  seriously  impede  the  recuperative  process.     In  the  ideal  climate 


426  GENERAL  DISEASES. 

there  should  be  stillness  of  the  air,  freedom  from  fog,  moisture,  and  dust, 
and  abundant  sunshine.  For  those  who  cannot  leave  England,  it  may  be 
consoling  to  know  that  good  results  have  followed  wintering  at  Torquay, 
Falmouth,  Bournemouth,  Hastings,  Ventnor,  Deeside,  Forres,  etc.  Their 
climates  are  not  ideal,  but  they  get  a  fair  amount  of  sunshine,  and  they 
are  provided  with  comfortable  hotels.  It  is  possible  at  most  of  these 
places  for  patients  to  find  shelter  out  of  doors  from  wind  and  rain.  Two 
of  the  best  winter  resorts  in  Europe  with  which  I  am  acquainted  are  Davos 
and  St.  Moritz  in  Switzerland.  The  advantages  of  these  resorts  are 
stillness  and  dryness  of  the  air,  freedom  from  dust,  and  a  considerable 
amount  of  bright  sunshine.  In  consequence  of  the  clearness  of  the 
atmosphere,  the  sun's  rays  have  great  warming  power.  As  a  result  of  the 
stillness  and  dryness  of  the  air,  a  high  degree  of  cold  can  be  tolerated 
without  discomfort.  The  air  has  a  wonderfully  stimulating  effect  upon  the 
appetite,  and  the  patient  becomes  capable  of  assimilating  a  much  larger 
quantity  of  food  than  is  the  case  at  home.  Patients  are  able  to  spend  the 
greater  part  of  the  day  in  the  open  air.  It  is  only  during  the  winter, 
however,  that  the  climate  of  Davos,  or  of  the  Engadine,  has  special  advan- 
tages. In  May  and  June  the  weather  is  notoriously  uncertain,  and  rain 
and  wind  are  often  prevalent. 

It  is  important  to  impress  on  patients  who  are  sent  to  winter  in  these 
parts  that  health  must  be  put  before  pleasure.  Many  who  might  have 
benefited  from  the  climate  have  done  themselves  harm  by  over-exertion  in 
skating,  tobogganing,  the  sport  of  the  "  ski,"  dancing,  etc.  The  patient 
who  is  anxious  to  regain  his  health  should  spend  as  little  time  as  possible 
in  the  public  rooms,  should  avoid  all  entertainments,  and  should  be 
guided  as  to  the  amount  and  kind  of  exercise  by  the  medical  adviser  on 
the  spot. 

The  question  arises,  whether  the  rarefaction  of  the  air  plays  any 
important  role  in  the  results  of  residence  at  high  altitudes.  To  us  it  seems 
impossible  to  separate  this  element  from  the  other  features,  and  we  do  not 
think  that  rarefied  air  per  se  has  any  appreciable  influence,  beneficial  or 
otherwise.  There  are  several  classes  of  cases  which  are  unsuitable  for 
the  cold  high  altitude  treatment.  Such  are  advanced  cases  of  all  kinds, 
acute  cases  with  high  fever,  cases  in  which  there  is  laryngeal  disease, 
heart  disease,  or  albuminuria,  cases  in  which  diarrhoea  is  a  prominent 
symptom,  cases  in  which  there  is  a  natural  repugnance  to  cold,  and 
cases  of  patients  of  advanced  age  with  emphysema.  Early  cases  in 
which  the  disease  is  not  active  are  those  in  which  the  best  results  may 
be  hoped  for. 

The  Riviera  as  a  resort  for  tuberculous  patients  combines  considerable 
advantages  with  serious  drawbacks.  It  offers  bright  sunshine  and  a 
luminous  atmosphere.  The  air  is  balmy,  genial,  dry,  exhilarating,  and 
bracing.  The  scenery  is  beautiful,  the  vegetation  luxuriant.  The  draw- 
backs are,  that  the  winds  are  chilly  and  change  twice  a  day,  that  the 
mornings  and  evenings  are  cold,  and  that  frequently  it  is  too  hot  in 
the  sun  and  too  cold  in  the  shade.  Hyeres,  Cimiez,  Mentone,  and  San 
Eemo  are  the  most  suitable.  Mce  can  never  be  recommended  for  cases 
of  phthisis.  At  Cannes  the  variations  of  temperature  are  great,  and  special 
care  is  required  if  the  invalid  is  permitted  to  winter  there. 

Madeira  and  the  Canaries  have  always  had  a  considerable  reputation  as 
health  resorts  for  consumptives,  perhaps  greater  at  one  time  than  they 
have   now.      The  excessive   moisture   and   relaxing;   climate   of   Madeira 


TUBERCULOSIS.  427 

render  it  unsuitable  in  most  cases.  Grand  Canary  is  preferable  to 
Teneriffe,  and  both  are  drier  and  more  bracing  than  Madeira. 

Farther  afield,  as  a  resort  for  phthisical  patients,  we  may  mention 
Egypt.  In  winter  the  desert  air  is  dry,  stimulating,  and  exhilarating. 
There  is,  as  a  rule,  an  almost  complete  absence  of  rain  and  abundant  bright 
sunshine.  The  mean  winter  temperature  is  62°  F.  The  disadvantages 
are  like  those  of  the  Eiviera — occasional  cold  high  winds  often  accompanied 
by  dust,  sudden  changes  of  temperature  between  day  and  night,  and  great 
differences  between  the  sun  and  shade  temperatures.  Cairo  is  totally 
unsuited  for  the  invalid,  who  should  winter  either  at  Helouan  or  Mena 
House  near  Cairo,  or  at  Luxor  or  Assouan  up  the  Nile.  Invalids  are  not 
advised  to  remain  in  Egypt  after  the  end  of  March  or  middle  of  April. 
Egypt  should  be  avoided  by  patients  in  whom  there  is  a  tendency  to 
diarrhoea,  fever,  or  active  pulmonary  disease. 

The  medical  man  is  often  asked  his  opinion  as  to  the  Cape  and 
Australia.  It  might  be  as  pertinent  to  ask  him  his  opinion  of  Europe  as  a 
health  resort.  In  many  parts  of  Australia  and  of  the  Cape  the  patient 
with  phthisis  is  infinitely  worse  off  than  in  England.  In  certain  parts  of 
the  Cape  the  climate  is  magnificent,  but  the  sanitary  arrangements  are 
generally  defective,  and  the  hotels  inferior.  Graham's  Town  (1800')  in 
the  Eastern  Province,  Aliwal  North  (4348'),  Cradock  (2850'),  Tarkastad 
(4280')  with  good  hotel,  and  Burghersdorp  (4650')  in  the  Karroo,  and 
Bloemfontein  (4500')  in  the  Orange  River  Colony,  are  among  the  resorts 
most  favourably  spoken  of.  Recently  a  large  sanatorium  has  been  opened 
at  Kimberley  (4360')  in  Griqualand  West. 

The  large  towns  in  Australia  (Melbourne,  Sydney,  etc.)  should  be  given 
a  wide  berth  by  the  tuberculous.  Hobart  Town  in  Tasmania,  Hay, 
Deniliquin,  and  Bathurst  in  New  South  Wales,  and  Toowoomba  and 
Warwick  on  the  Darling  Downs  in  Queensland,  are  among  the  most 
suitable  resorts,  but  in  most  of  these  places  indifferent  food  and  accom- 
modation must  be  set  against  climatic  advantages. 

In  the  United  States,  Colorado  Springs  (6000'),  with  a  climate  in  winter 
much  resembling  that  of  Davos  in  Switzerland,  cold  but  dry  and  sunny,  has 
a  decidedly  curative  effect.  It  is  occasionally  visited  by  blizzards,  but  this 
is  almost  its  only  drawback.  The  Adirondacks  and  the  district  about 
Liberty  in  Sullivan  County  (N.Y.)  have  also  a  high  reputation  among 
American  physicians. 

A  sea-voyage  may  be  suitable  in  certain  cases.  Where  the  disease  is 
early,  fever  little  or  absent,  and  the  patient  a  good  sailor,  and  in  easy 
enough  circumstances  to  travel  comfortably,  great  good  may  result  from  a 
journey  to  Australia  and  back  by  the  Cape.  Some,  even  of  my  poorer 
patients,  who  have  gone  a  voyage  against  my  advice,  have  greatly  benefited, 
although  in  others  the  malady  has  rapidly  advanced.  Walshe  speaks  of 
benefit  even  in  advanced  cases,  but  a  voyage  can  never  be  advised  to  such 
patients.  I  should  feel  much  more  disposed  to  recommend  a  sea-voyage 
after  all  activity  of  the  disease  had  ceased,  and  when  it  is  important  to 
establish  the  health  on  a  firm  basis. 

Sanatorium  treatment. — It  is  only  during  the  last  few  years  that  the 
great  value  of  sanatorium  treatment  has  been  properly  appreciated  in  this 
country,  although  for  many  years  it  has  been  adopted  on  the  Continent. 
The  pioneer  in  this  line  of  treatment  seems  to  have  been  George  Boding- 
ton  of  Sutton  Coldfield,  who  in  1839  started  a  home  for  consumptives, 
believing   that  great  advantages  were  to  be   derived   from   "systematic 


428  GENERAL  DISEASES. 

arrangements  with  regard  to  exercise,  diet,  and  general  treatment,  with 
the  watchfulness  daily,  nay  almost  hourly,  over  a  patient  of  a  medical 
superintendent."  He  advocated  a  generous  diet,  and  fresh  air  night  and 
day.  Another  physician  who  early  insisted  on  the  value  of  fresh  air  night 
and  day  was  Henry  MacCormac  of  Belfast.  But  it  was  Hermann  Brehmer 
who  first  successfully  inaugurated  the  sanatorium  treatment  in  1859. 
Firmly  believing  in  the  curability  of  phthisis  in  its  early  stages,  he  started 
a  small  sanatorium  in  G-orbersdorf  in  Silesia.  He  chose  a  spot  charmingly 
situated  among  the  hills,  at  an  elevation  of  1840'.  At  this  height  he 
fancied  that  there  was  a  natural  immunity  from  tubercle,  and  he  considered 
that  hill  climbing  formed  an  important  part  of  the  treatment.  From  this 
small  beginning  the  Gorbersdorf  sanatorium  has  now  become  the  largest  of 
the  kind  in  the  world. 

Of  the  many  other  sanatoria  which  have  been  instituted  on  lines 
similar  to  Brehmer's  establishment,  the  following  may  be  mentioned. 
Falkenstein  (1300'),  in  the  Taunus  mountains,  conducted  for  many  years 
by  Dettweiler;  Beiboldsgriin  (2460'),  in  Saxony,  among  the  Erzgebirge, 
delightfully  situated  amidst  a  dense  pine  forest;  ISTordrach  Colonie  (1500'), 
in  the  Black  Forest ;  Hohenhonnef  (735'),  on  the  Siebengebirge ;  Leysin 
(4750'),  in  Canton  de  Vaud,  Switzerland,  principally  frequented  by  the 
French;  and  Arosa  (6150'),  not  far  from  Davos.  We  may  also  add  to 
the  list  the  Adirondack  Cottage  Sanatorium  for  poor  patients,  started  by 
Trudeau,  and  the  Loomis  Sanatorium  (2200')  in  Sullivan  County,  for 
persons  of  limited  means,  both  in  the  State  of  New  York.  Becently  a 
large  number  of  private  sanatoria  for  paying  patients  have  been  opened 
in  various  parts  of  the  United  Kingdom.  In  most  of  these  the  arrange- 
ments have  been  modelled  on  those  at  Nordrach. 

The  arrangements  at  some  Continental  sanatoria  are  far  from  perfect, 
especially  with  regard  to  ventilation  of  sleeping  and  public  rooms,  baths, 
medical  supervision,  etc.,  but  on  the  whole  sanatoria  are  usually  a  great 
deal  better  for  patients  than  the  ordinary  hotels.  Many  of  the  hotels 
in  the  high  altitudes  in  Switzerland,  as  has  been  said  with  some  justice, 
seem  to  have  une  spe'cialite  de  la  viancle  dure,  and  it  is  a  hard  struggle 
for  the  invalid  to  eat  the  ordinary  meals  of  the  table  d'hote. 

The  excellent  results  obtained  at  such  sanatoria  as  those  mentioned  show 
that  much  may  be  done  in  the  treatment  of  phthisis  by  modifying  the  mode 
of  life  under  constant  medical  supervision,  even  where  the  climate  is  by 
no  means  ideal,  and  the  altitude  is  moderate.  The  sanatoria  usually 
occupy  sites  sheltered  from  the  prevailing  winds  and  where  surrounding 
pine  woods  secure  freedom  from  dust.  The  mode  of  treatment  adopted  at 
these  establishments  has  for  its  special  features  constant  medical  super- 
vision, the  open-air  life  which  the  patients  are  made  to  lead,  the  adminis- 
tration of  abundant  and  nourishing  food,  and  the  removal  from  home 
surroundings,  home  worries,  and  the  solicitude  of  over-anxious  friends, 
rest  during  the  febrile  stage,  and  graduated  exercises  and  hill  climbing 
when  the  fever  is  past. 

To  enable  the  patients  to  be  as  much  in  the  open  air  as  possible,  there 
are  at  some  of  the  sanatoria  verandahs  and  summer-houses  fitted  with 
couches  where  they  can  recline.  The  shelters  are  either  open  on  one  side 
and  revolving,  or  fitted  with  movable  shutters  so  as  to  obtain  shelter  from 
wind  or  sun.  The  patients  are  led  to  look  for  warmth  to  extra  clothing, 
rather  than  to  shutting  out  fresh  air  because  it  is  cold.  Weak  and  elderly 
patients  lie  near  the  open  windows  in  their  rooms.      In  this  way  the 


TUBERCULOSIS. 


429 


patient  lives   more  or   less   continuously  in  the  open   air.      Exercise  is 
regulated  according  to  the  strength  of  the  patients. 

The  mode  of  feeding  is  adapted  to  individual  cases.  The  food  is  well 
cooked,  appetising,  and  varied.  Ordinary  meals  are  supplemented  by  milk, 
soups,  and  broths.  At  Nordrach  only  three  meals  a  day  are  allowed,  no 
food  being  taken  between.  The  quantity  of  food  ordered  is  sometimes 
greatly  in  excess  of  what  is  taken  by  a  strong,  healthy  working  man.  It 
must  be  remembered  that  the  cases  which  are  likely  to  do  well  at  these 
sanatoria  are  the  early  or  inactive  cases,  and  advanced  or  actively  progress- 
ive cases  should  never  be  sent  to  them. 

Special  treatment. — We  shall  now  consider  the  treatment  of  some  of 
the  special  symptoms. 

Alimentary  system. — It  is  always  important  to  improve  the  appetite 
and  strengthen  the  digestive  powers.  An  alkali  in  a  bitter  infusion,  taken 
a  short  time  before  meals,  sometimes  works  wonders.  A  mixture  contain- 
ing 15  grs.  of  bicarbonate  of  soda,  and  3  minims  of  dilute  hydrocyanic  acid  to 
the  ounce  of  compound  infusion  of  gentian,  has  a  great  reputation  among  the 
patients  at  the  Brompton  Hospital.  Sometimes  an  acid  mixture  containing 
dilute  phosphoric  acid  with  a  bitter  infusion  suits  better  than  an  alkaline. 
If  there  is  constipation  it  must  be  relieved.  A  useful  pill  in  ordinary 
cases  is  aloin,  1  gr. ;  extr.  bellad.,  extr.  nuc.  vom.,  aa  \  gr.  One  or  two  of 
these  may  be  taken  in  the  evening.  If  the  tongue  is  furred,  an  occasional 
dose  of  calomel  will  benefit.  The  treatment  of  diarrhoea  is  considered 
under  the  heading  of  Tuberculosis  of  the  Intestines. 

Cough. — Eoutine  treatment,  whether  by  sedatives  or  expectorants,  is 
bad.  As  far  as  possible,  cough  mixtures,  linctuses,  etc.,  should  be  avoided. 
Eelief  may  be  obtained  by  sipping  lemon  or  barley-water,  or  toast  and 
water,  or  demulcent  drinks,  such  as  decoction  of  iceland  moss  or  linseed 
tea.  Lozenges  of  various  kinds  are  useful,  such  as  troch.  ipecac.  (B.P.),  or 
troch.  glycyrrhiz.  (Brompton  Hosp.  Phar.).  If  the  cough  is  harassing  at 
night,  preventing  sleep  and  rest,  a  linctus  may  be  necessary.  In  a  linctus, 
a  small  dose  of  dilute  sulphuric  acid,  opium,  morphine,  codeine,  paregoric, 
or  squill,  is  combined  with  syrups  of  various  kinds  (treacle,  honey,  or 
oxymel)  and  water,  care  being  taken  that  the  preparation  is  neither  too 
sweet  nor  too  thick.  Sometimes  inhalations  of  menthol,  creosote,  or 
terebene  are  more  efficient  in  quieting  paroxysms  of  coughing  than 
remedies  by  the  mouth.  Twenty  minims  of  a  solution  consisting  of  equal 
parts  of  a  20  per  cent,  alcoholic  solution  of  menthol,  creosote,  and  spirit  of 
chloroform  dropped  on  the  sponge  of  an  inhaling  respirator,  may  be  men- 
tioned as  a  useful  form  of  dry  inhalation.  The  ordinary  compound  benzoin 
inhalation  (tr.  benzoin,  co.,  1  drm.  to  a  pint  of  water  at  140°  P.)  is  some- 
times soothing.  Sprays  to  the  back  of  the  pharynx  may  be  tried  when 
other  measures  fail.  A  2  per  cent,  solution  of  cocaine  or  of  menthol  is 
very  suitable  for  this  purpose.  When  the  cough  is  accompanied  by  tick- 
ling, smarting,  or  pricking  sensations  in  the  throat,  a  small  blister  or 
mustard  leaf,  or  even  a  hot  poultice,  applied  externally  at  the  side  of  the 
larynx,  will  sometimes  relieve. 

Pits  of  coughing,  terminating  in  vomiting,  sometimes  come  on  just  after 
a  meal.  In  such  cases  the  soda  mixture  previously  mentioned  may  be  of 
service.  Sometimes  5  minims  of  liquor  potassse,  with  5  grs.  of  alum,  taken 
shortly  before  the  meal,  will  prevent  the  cough  and  vomiting.  In  other 
cases,  a  dose  of  a  few  drops  of  laudanum,  chlorodyne,  or  tincture  of  mix 
vomica  before  the  meal  proves  more  efficacious. 


43°  GENERAL  DISEASES. 

'Haemoptysis. — The  patient  should  be  kept  in  bed  at  perfect  rest 
until  the  bleeding  has  entirely  ceased.  He  should  not  be  allowed  to  talk. 
In  the  case  of  a  first  haemoptysis,  and  sometimes  in  subsequent  attacks, 
the  patient  is  in  a  highly  nervous  state,  and  the  physician  can  do  much  to 
allay  his  fears.  A  hypodermic  injection  of  morphine  (\  gr.)  will  soothe 
the  patient  and  produce  that  condition  of  repose  which  is  so  essential. 
An  ice-bag  may  be  applied  to  the  front  of  the  chest  if  the  haemorrhage 
continues.  A  hot-water  bottle  to  the  feet  is  advisable,  if  they  are  at  all 
chilly. 

The  diet  should  be  limited  to  two  pints  of  milk,  with  a  little  bread 
and  butter,  custard,  or  jelly,  as  long  as  the  haemorrhage  continues.  Stimu- 
lants, it  is  needless  to  say,  should  be  forbidden.  Various  haemostatics  have 
been  used  from  time  to  time.  Hamamelis,  oil  of  turpentine,  and  ergot  are 
the  best  of  these.  Twenty  to  60  minims  of  the  tincture  of  hamamelis, 
10  minims  of  oil  of  turpentine  in  capsules,  or  1  to  3  grs.  of  ergo  tin  in 
hypodermic  injection,  may  be  given. 

When  haemoptysis  is  persistent,  either  stimulants  or  depressants  may 
be  required.  If  the  pulse  is  rapid  and  feeble,  digitalis  and  alcohol, 
cautiously  administered  in  small  doses,  may  do  much  good.  In  such  cases 
the  bleeding  is  probably  kept  up  by  passive  congestion.  If,  on  the  other 
hand,  the  pulse  is  strong  and  sustained,  antimony  sometimes  acts  better  than 
any  other  remedy.  A  solution  of  tartar  -emetic,  1  gr.  to  the  half-pint, 
may  be  ordered,  and  the  patient  may  take  of  this  a  teaspoonful  every 
half-hour,  while  the  effect  is  watched.  Attention  should  be  directed  to 
the  state  of  the  bowels.  A  mild  purge  is  advisable  in  ordinary  cases. 
When  the  patient  is  plethoric  or  alcoholic,  aperients  form  the  most  im- 
portant part  of  the  treatment.  A  couple  of  grains  of  calomel  may  be 
given  at  night,  followed  by  a  saline  aperient  mixture  in  the  morning,  and 
repeated  when  necessary. 

Sweating  at  night  is  often  a  source  of  great  discomfort  to  the  patient, 
and  its  treatment  necessarily  demands  attention.  The  amount  of  clothing 
and  the  proper  ventilation  and  temperature  of  the  sleeping  apartment  must 
be  studied.  It  is  well,  when  the  sweating  occurs  in  the  early  morning, 
that  the  patient  should  be  sponged  with  tepid  water,  and  should  have  a 
small  amount  of  food  and  stimulant  at  that  time.  The  whole  of  the  body 
should  be  frequently  washed  with  warm  water. 

There  are  several  remedies  which  exert  some  control  over  night 
sweating.  Among  these  are  oxide  of  zinc,  belladonna  or  atropine,  nux 
vomica  or  strychnine,  agaricin,  picrotoxin,  and  camphoric  acid.  Five  grs. 
of  oxide  of  zinc  may  be  given  in  the  form  of  a  pill,  alone  or  combined  with 
half  a  grain  of  extract  of  belladonna.  Liquor  atropinae  sulph.  may  be 
given  in  minim  doses,  extract  of  nux  vomica  in  half-grain  doses,  liquor 
strychninae  hydrochloridi  in  10  minim  doses,  agaricin  in  doses  of  -^  gr., 
picrotoxin  in  doses  of  ■£$■  gr.,  and  camphoric  acid  in  doses  of  20  to  30  grs. 
Sometimes  one  remedy  will  succeed  when  another  fails. 

The  medicinal  treatment  of  fever  has  not,  so  far,  been  very  success- 
ful. Every  known  antipyretic  has  been  tried  more  or  less,  but  with  very 
little  apparent  result  on  the  temperature,  and  but  little  benefit  to  the 
patient.     As  a  rule,  the  case  should  be  treated  on  general  principles. 

Whenever  there  is  continued  fever,  the  patient  should  be  kept  at  rest  in 
bed;  but  when  fever  is  only  slight,  the  morning  temperatures  normal,  and  but 
little  elevation  at  night,  he  may  be  up  most  of  the  day.  Persistent  fever, 
although  an  indication  for  rest  in  bed,  does  not  contra-indicate  sunshine 


TUBERCULOSIS.  431 

and  fresh   air,  and,  whenever   possible   without   disturbance   or  fatigue, 
the  patient  should  be  allowed  out  of  doors. 

Tepid  sponging,  at  the  time  when  the  temperature  is  highest,  will 
often  promote  the  comfort  of  the  patient.  Cradling  is  another  method 
for  reducing  the  temperature.  In  this  method  the  bedclothes  are  raised 
from  immediate  contact  by  means  of  a  wire  bed-cradle,  the  cooling  effect 
of  which  may  be  increased  by  the  suspension  of  ice-bags  underneath  the 
cradle.  If  the  latter  are  used,  care  should  be  taken  to  prevent  dripping 
from  the  condensed  vapour  which  collects  on  their  exterior. 

Pneumothorax. — At  the  outset,  if  there  is  shock,  diffusible  stimulants 
should  be  given,  and  if  pain  and  nervous  excitement,  opium  or  morphine 
should  be  administered.  If  there  is  much  dyspnoea,  relief  may  be  afforded 
by  tapping  by  means  of  a  syphon  arrangement.  If,  in  spite  of  this, 
dyspnoea  increases,  dry  or  wet  cupping  or  venesection  are  sometimes 
useful.  In  the  later  stage,  if  fluid  is  effused,  part  of  it  should  be  drawn  off 
by  syphonage  after  a  few  weeks.  In  the  case  of  a  pyopneumothorax, 
opinions  are  divided  as  to  the  best  mode  of  treatment.  Many  surgeons 
are  opposed  to  operative  measures.  Samuel  West,  however,  strongly 
advocates  treatment  by  incision  and  drainage,  as  in  the  case  of  empyema. 
Tapping  never  affords  more  than  temporary  relief  in  pyopneumothorax. 

Treatment  of  chronic  tuberculosis  from  a  bacteriological  stand- 
point.— Two  kinds  of  immunity  are  now  recognised  in  the  diseases  due  to 
bacteria.  One  is  immunity  to  the  toxine  produced  by  the  bacilli,  the  other 
is  immunity  to  the  bacilli  themselves.  Thus,  animals  can  be  immunised 
against  the  toxine  of  tetanus  but  not  against  the  microbes  ;  while,  in  the 
case  of  enteric  fever  and  cholera,  they  can  be  immunised  against  the 
microbes  but  not  against  the  toxines.  To  be  complete,  immunity  should 
combine  both  these  elements.  The  ordinary  course  of  pulmonary  tuber- 
culosis does  not  encourage  the  hope  that  any  natural  immunity  is  pro- 
duced. The  malady  may  go  on  for  years  without  any  sign  of  immunity 
appearing.  Fresh  outbreaks,  as  we  know,  are  not  uncommon  even  after 
arrest  has  occurred. 

Certain  facts  observed  by  Koch  encourage  the  belief  that  immunity 
is  possible.  In  acute  miliary  tuberculosis  there  is  a  stage  in  which 
the  bacilli,  at  one  time  abundant,  become  so  few  that  they  are  difficult 
to  find  ;  and  this  disappearance  is  the  more  remarkable,  because 
ordinarily  the  bacilli,  even  when  dead,  are  absorbed  very  slowly  indeed. 
This  suggests  that  a  process  of  immunisation,  purely  bacterial,  has 
been  brought  about,  but  too  late  to  be  of  benefit.  Koch  believes 
that  in  these  cases  of  apparent  immunisation  the  body  is  as  it  were 
inundated  in  a  short  time  with  the  micro-organisms.  The  immunity 
only  comes  after  absorption  or  digestion  of  the  bacilli.  The  reason 
that  no  immunity  ordinarily  occurs,  is  that  the  bacilli  attain  their 
development  only  in  small  numbers  in  the  human  body.  They  are 
environed  by  dead  tissues,  and  are  only  absorbed  long  after  when  they 
are  themselves  dead,  and  have  undergone  profound  changes.  In  the  parts 
where  the  tubercles  grow,  as  in  cavities  and  at  the  surface  of  mucous 
membranes,  the  bacilli  are  eliminated  without  undergoing  modifications, 
and  are  not  absorbed  at  all.  The  problem  to  which  Koch  set  himself  was 
to  try  and  bring  about  artificially  this  absorption  and  digestion  of  the  bacilli. 
Koch  first  attempted  to  extract  from  the  bacilli  their  active  principle, 
and  by  administering  subcutaneous  injections  of  the  extract  to  bring  about 
immunity.      In  this,  as  we  shall  see,  he  was  not  altogether  successful. 


432  GENERAL  DISEASES 

Eecently,  by  pulverising  the  bacilli,  he  has  obtained  principles  incapable  of 
extraction  otherwise. 

Tuberculin,  a  principle  extracted  from  the  bacilli,  was  originally  intro- 
duced by  Koch  (1890)  as  a  curative  agent.  The  mode  of  preparation  was 
as  follows.  The  bacilli  are  grown  for  six  or  eight  weeks  in  a  slightly 
alkaline  veal  broth,  ,to  which  had  been  added  1  per  cent,  of  peptone  and 
4  to  5  per  cent,  of  glycerin.  The  medium  containing  the  bacilli, 
having  been  evaporated  to  a  tenth  of  its  bulk  in  a  water-bath  placed  in 
boiling  water,  is  filtered  through  porcelain.  The  filtrate  is  tuberculin,  a 
clear  brownish  fluid  containing  40  to  50  per  cent,  of  glycerin,  which 
keeps  it  aseptic.  If  any  bacilli  are  present  in  the  liquid,  one  may  rest 
assured  that  they  have  been  killed  by  the  mode  of  preparation. 

Various  attempts  have  been  made  to  purify  the  tuberculin  so  prepared. 
On  treatment  with  alcohol  a  precipitate  is  obtained.  This  precipitate, 
dissolved  in  water  and  treated  with  a  mixture  of  alcohol,  chloroform,  and 
crystallised  benzol,  is  the  tuberculocidin  of  Klebs.  To  a  liquid  still  further 
purified,  Klebs  has  given  the  name  of  antiphthisin.  Tuberculin  in  doses  of 
0*25  c.c.  produces  an  intense  reaction  in  a  healthy  adult.  In  a  tuberculous 
adult  a  much  smaller  dose,  0*01  c.c,  produces  both  a  general  and  a  local 
reaction.  Tour  or  five  hours  after  the  injection  the  temperature  rises 
4  or  5°,  and  this  rise  is  often  ushered  in  with  a  rigor  and  attended  by 
general  malaise,  pains  in  the  limbs,  and  sometimes  vomiting.  These  symp- 
toms pass  off  in  twelve  to  fifteen  hours.  The  local  reaction  can  be  best 
studied  in  cases  of  cutaneous  tuberculosis.  The  lupus  patch  reddens  and 
swells  up,  even  before  the  constitutional  symptoms  manifest  themselves. 
The  swelling  diminishes  in  general  with  the  fever,  and  the  patch  becomes 
covered  with  crusts  formed  by  dried  exudation,  which  separate  at  the  end  of 
two  or  three  weeks.  A  similar  but  slighter  local  reaction  can  be  observed 
in  the  case  of  tuberculous  glands  and  joints.  In  the  case  of  pulmonary 
tuberculosis,  there  is  an  increase  of  cough  and  of  expectoration,  together 
with  signs  of  increased  activity  of  the  local  disease.  By  repetition  of  the 
dose,  it  is  possible  to  greatly  increase  the  amount  which  can  be  borne. 

In  the  subject  of  pulmonary  tuberculosis  a  much  smaller  dose  is  needed 
to  produce  reaction  than  in  the  case  of  lupus.  Thus,  0'001  c.c.  may  at  first 
be  sufficient  to  produce  a  marked  reaction,  although  later  0-01  c.c.  or  more 
may  be  borne  with  even  less  reaction.  Although  Koch  had  great  hopes 
that  tuberculin  was  curative,  and  believed  that  the  tolerance  of  the  sub- 
stance gradually  brought  about  was  due  to  the  progressive  destruction  of 
the  tuberculous  tissue,  these  hopes  were  not  realised.  Even  in  the  case  of 
lupus,  the  improvement  was  found  to  be  only  temporary.  The  reaction 
following  the  administration  of  tuberculin  proved  to  have  a  high  diagnostic 
value,  and  much  use  has  been  made  of  it  for  the  recognition  of  tuberculosis 
in  cattle.  Opinions  differ,  however,  as  to  its  worth  as  a  diagnostic  agent 
in  early  tuberculosis  in  the  human  being.  It  is  known  that  the  reaction 
occurs  in  cases  of  leprosy,  syphilis,  actinomycosis,  and  cancer. 

For  diagnosis  the  initial  dose  should  be  0-005  c.c.  If  this  gives  no 
reaction,  another  dose  of  001  c.c.  maybe  given  in  three  days'  time.  If  this 
has  no  effect,  a  third  of  0-02  c.c.  may  be  administered.  If  slight  symptoms 
are  produced  by  a  dose  of  0*02  c.c,  a  fourth  injection  of  0-03  c.c  may  be 
necessary  to  attain  a  positive  conclusion. 

A  new  tuberculin  was  more  recently  (April  1897)  introduced  by  Koch. 
Dried  cultures  of  tubercle  bacilli  are  ground  up  in  an  agate  mortar.  The 
resulting  powder  is  mixed  with  distilled  water  and  centrif ugalised.    The  solid 


TUBERCULOSIS.  433 

residue  so  obtained  is  dried,  again  pounded,  mixed  with  distilled  water,  and 
the  liquid  centrifugalised.  The  process  can  be  repeated  until  no  residue  is 
left.  The  liquid  obtained  from  the  first  centrifugalisation  is  called  tuber- 
culin-0  (oberste).  That  from  the  second  and  subsequent  centrifugalisations 
is  called  tuberculin-E  (rest).  The  tuberculin-0  produces  almost  identical 
results  with  those  of  ordinary  tuberculin,  while  tuberculin-E  does  not  pro- 
duce reaction  except  in  large  doses,  but,  according  to  Koch,  possesses 
immunising  properties.  Tuberculin-E  has  not  realised  expectations  either 
as  an  immunising  or  therapeutic  agent. 

Maragliano  and  others  have  attempted  to  produce  an  immunising  or 
curative  serum.  Animals  are  inoculated  in  gradually  increasing  doses,  with 
toxic  substances  derived  from  virulent  cultures.  The  animal  is,  after  a 
time,  found  to  resist  the  injection  of  cultures  virulent  enough  to  kill  a 
control  animal.  Treatment  with  serum  of  an  animal  so  immunised  must 
be  considered  to  be  at  present  still  in  the  experimental  stage. 

TUBEECULOSIS  OF  THE  GENITO-UEINAEY  SYSTEM. 
Urinary  Organs. 

Etiology. — Tuberculous  disease  of  the  kidney  is  usually  primary, 
although  some  have  held  that  it  is  often  secondary,  arising  by  extension 
upwards  along  the  ureter  from  tubercle  of  bladder  or  genital  tract.  Some 
have  even  maintained  that  the  cause  was  direct  infection  of  the  generative 
organs,  as,  for  example,  from  a  tuberculous  husband  to  a  healthy  wife. 
Such  a  mode  of  infection  is  out  of  the  question  in  a  large  proportion  of 
the  cases  met  with  in  practice. 

At  first  the  disease  is  limited  to  one  kidney;  and,  when  both  are 
attacked,  it  is  always  more  advanced  in  one  than  in  the  other.  Eagge 
found,  out  of  thirty-four  cases,  in  twenty -two  one  kidney  only  was  involved. 
The  left  kidney  has  been  observed  to  be  rather  more  frequently  the  seat 
of  tubercle  than  the  right.  Out  of  eight  fatal  cases  at  St.  Thomas's  Hospital, 
in  four  both  kidneys  were  affected,  and  one  only  in  the  remainder.  Tuber- 
culous disease  of  the  bladder  is  more  often  secondary  than  primary,  but 
cases  of  the  latter  type  do  occur.  It  is  more  common  in  males  than  in 
females,  and  most  frequently  occurs  in  the  age  period  twenty  to  thirty. 

Morbid  anatomy. — Miliary  tubercle  commonly  occurs  in  the  kidney, 
when  there  is  general  miliary  tuberculosis.  It  was  noted  present  in  thirty- 
four  out  of  496  cases  of  pulmonary  tuberculosis,  examined  post-mortem  at 
the  Brompton  Hospital.  The  tubercles  appear  as  greyish  white  spots,  about 
the  size  of  pins'  heads,  and  are  generally  most  easily  recognised  on  the  sur- 
face after  stripping  off  the  capsule,  although  they  may  also  be  seen  scattered 
through  the  organ.     They  are  usually  comparatively  few  in  number. 

Caseous  tubercle  in  the  kidneys  may  be  met  with  in  the  form  of 
scattered  nodules  in  cases  of  pulmonary  tuberculosis,  but  most  frequently 
it  is  found  in  the  form  of  local  tuberculous  disease  of  kidney,  scrofulous 
kidney,  or  renal  phthisis,  as  it  has  been  called.  This  form  is  very  rarely 
secondary  to  pulmonary  tuberculosis.  Caseous  tubercle  is  most  frequently 
deposited  at  the  apices  of  the  pyramids,  but  may  be  found  anywhere, 
either  in  the  cortex  or  medulla.  Sooner  or  later  the  caseous  mass 
softens,  and  is  discharged,  either  directly  into  the  pelvis,  or  is  retained  in 
the  interior  of  an  abscess  cavity.  The  kidney  substance  is  gradually 
destroyed,  and  cavities  are  formed,  with  caseous  walls  separated  by  septa. 
vol.  1. — 28 


434  GENERAL  DISEASES. 

In  advanced  cases  the  organ  may  be  converted  into  a  multiloculated  cyst, 
with  little  or  no  kidney  substance  remaining.  A  perinephritic  abscess 
sometimes  forms  about  the  diseased  organ.  The  organ,  as  a  rule,  is  but 
little  enlarged,  except  when  there  is  obstruction  of  the  ureter  and 
pyonephrosis.  The  pelvis  of  the  kidney,  sooner  or  later,  is  affected,  and  its 
interior  becomes  lined  with  cheesy  material.  Its  cavity  probably  dilates, 
and  is  filled  with  curdy  pus,  and  occasionally  calculi  form  in  its  interior. 
The  ureter,  also,  in  many  cases  becomes  diseased.  Its  mucous  membrane 
may  be  studded  with  tubercle,  or  ulcerated  in  patches  or  throughout  its 
entire  length,  while  on  its  interior  curdy  matter  is  deposited.  The  walls 
may  be  extremely  thickened,  while  the  lumen  is  narrowed,  and  occasionally 
may  be  completely  occluded.  Very  rarely  the  ureter  may  be  the  only  part 
of  the  urinary  tract  affected. 

The  mucous  membrane  of  the  bladder,  like  the  kidney,  may  be  invaded 
by  miliary  tubercles,  which  may  be  few  or  numerous.  Nodules  of  crude 
caseous  tubercle,  and  ulcers,  varying  in  size,  shape,  and  depth,  may  also  be 
present.  At  first  the  ulcers  are  quite  superficial  and  small,  but  they  tend 
to  spread  and  coalesce,  and  increase  in  depth.  The  most  usual  situation 
is  about  the  apex  of  the  trigone,  but  no  part  of  the  mucous  membrane 
may  escape.  Cases  have  been  reported  where  the  entire  mucous  mem- 
brane has  been  destroyed  by  ulceration,  and  the  muscular  coat  covered 
by  a  deposit  of  caseous  yellow  matter.  The  capacity  of  the  bladder  is 
greatly  diminished,  and  the  walls  are  thickened  partly  from  muscular 
hypertrophy  and  partly  from  chronic  inflammation.  Sometimes  the 
ulcerated  surface  is  the  seat  of  a  deposit  of  lime  salts.  Very  rarely  the 
ulceration  has  caused  perforation  of  the  bladder  and  acute  peritonitis. 
Tuberculous  ulceration  may  extend  into  the  urethra  for  an  inch  or  so. 
Very  rarely  tubercles  or  ulcers  may  be  found  in  its  entire  length,  up  to  an 
inch  or  so  from  the  meatus.  In  fatal  cases  it  is  quite  exceptional  for  the 
kidneys  to  be  tuberculous,  and  the  bladder  to  escape ;  but  sometimes  the 
bladder  is  affected  without  the  kidneys,  and  vice  versd.  Tuberculous 
deposits  are  nearly  always  found  to  be  present  in  other  organs. 

Symptoms. — Miliary  tubercle  in  the  kidneys  or  bladder  produces 
no  symptoms  by  which  its  presence  can  be  recognised.  The  symptoms 
caused  by  the  other  forms  of  tuberculous  disease  of  kidney  are  not  in 
themselves  specially  characteristic.  There  is  usually  pain  in  the  corre- 
sponding loin.  The  affected  kidney  can  sometimes  be  felt  to  be  distinctly 
enlarged,  and  may  be  tender  to  manipulation.  Often  the  organ  is  little, 
if  at  all,  increased  in  size. 

The  urine  sometimes  is  quite  normal.  It  is  generally  acid,  and  often 
contains  pus,  and  sometimes  albumin.  The  patient  may  have  observed 
that  it  is  thick  and  muddy,  or  that  it  deposits  a  sediment  on  standing. 
Hematuria  is  not  at  all  uncommon.  It  was  noted  in  eight  out  of  twenty- 
three  cases  treated  at  St.  Thomas's  Hospital ;  and  Fagge  found  that  it  was 
recorded  in  ten  out  of  eighteen  fatal  cases  at  Guy's  Hospital.  The  quan- 
tity of  blood  is  not  usually  large,  although  exceptionally  the  bleeding  has 
been  prolonged  and  profuse.  By  far  the  most  important  sign  is  the  pre- 
sence of  the  tubercle  bacilli  in  the  urine.  The  discovery  of  these  is  greatly 
facilitated  by  centrifugalising,  for  the  bacilli  are  generally  few  in  number, 
and  may  easily  be  missed.  It  may  be  well,  in  some  cases,  to  try  the  effect 
of  inoculating  guinea-pigs  with  the  sediment.  This  is  said  to  have  given 
positive  results  in  some  cases  where  tubercle  bacilli  have  not  been  found. 

It   is  very   important   not   to   mistake   the  smegma  bacillus  for  the 


TUBERCULOSIS.  435 

tubercle  bacillus.  The  smegma  bacillus  may  be  detected  in  the  urine  in  a 
large  proportion  of  female  cases,  although  it  is  rarely  present  in  male  cases. 
All  urine  which  is  to  be  examined  for  tubercle  bacilli  should,  in  the  case  of 
females,  be  drawn  off  by  catheter.  Grethe  says  that  by  counter-staining 
with  concentrated  alcoholic  methylene-blue,  after  staining  in  the  ordinary 
way  with  carbol-fuchsin,  the  tubercle  bacillus  is  easily  identified  by  its  red 
colour,  contrasting  with  the  blue  of  the  rest  of  the  preparation,  including 
the  smegma  bacillus.  Griinbaum  states  that  the  smegma  bacillus  can  be 
readily  differentiated  from  the  tubercle,  by  the  fact  that  two  minutes'  im- 
mersion in  dilute  alcohol  will  decolorise  the  former,  but  not  the  latter. 

Frequently,  superadded  to  the  symptoms  already  mentioned,  we  get 
others  connected  more  immediately  with  the  bladder.  Thus  there  may  be 
suprapubic  pain.  Most  commonly  there  is  abnormal  irritability  of  the 
bladder ;  the  patient  has  to  pass  water  at  short  intervals,  and  there  is  pain 
or  discomfort  in  micturition. 

Diagnosis. — In  the  absence  of  evidence  of  tuberculous  disease  else- 
where in  the  body,  a  positive  diagnosis  may  be  impossible  until  the  discovery 
of  bacilli  in  the  urine.  The  disease  may  be  confounded  with  renal  calculus. 
Sometimes  calculus  is  present  along  with  tuberculosis.  In  renal  calculus 
the  pain  is,  as  a  rule,  more  decided,  and  haeniaturia  is  more  frequent,  while 
the  urine  likely  does  not  contain  pus. 

Hydronephrosis  may  sometimes  be  mistaken  for  tuberculous  disease.  In 
this  case  there  is  a  more  distinct  tumour,  which  is  often  lobulated.  More 
diagnostic  is  the  variation  in  size  of  the  tumour,  which  sometimes  actually 
disappears,  this  being  immediately  preceded  by  the  passage  of  a  large 
quantity  of  urine.  Sometimes  the  ureter  has  been  so  thickened  by  tuber- 
culous deposit,  that  it  could  be  felt  through  the  abdominal  wall  as  a  hard, 
rigid  cord. 

Prognosis. — The  prognosis  cannot  but  be  gloomy  as  regards  recovery. 
Still  the  duration  of  the  disease  is  sometimes  long.  Thus,  in  five  cases  out 
of  twenty-three  observed  at  St.  Thomas's  Hospital,  the  disease  had  lasted 
over  four  years,  the  average  duration  being  six  years.  In  the  remainder 
the  duration  was  shorter — from  six  months  to  two  years.  Where  one  has 
reason  to  believe  that  the  disease  is  primary  in  the  kidney,  and  that  it  has 
not  spread  to  the  bladder  or  to  the  other  kidney,  the  possibility  of  radical 
cure  by  nephrectomy  must  be  borne  in  mind. 

Treatment. — A  case  of  renal  or  vesical  tuberculosis  may  be  treated 
on  general  principles,  such  remedies  being  employed  as  are  found  to  benefit 
in  tuberculous  disease  elsewhere,  but  little  prospect  of  arrest  or  cure  in  this 
way  can  be  held  out.  Unfortunately,  the  patient  does  not  as  a  rule  apply 
for  relief  until  the  disease  has  made  considerable  progress.  There  can  be 
no  question  that  when  tuberculosis  is  limited  to  one  kidney,  that  kidney 
should  be  excised.  We  know  that  if  such  a  case  is  left  to  itself,  the 
disease  will  gradually  extend  in  the  kidney,  will  probably  spread  along  the 
pelvis  to  the  ureter  and  bladder,  and  that  sooner  or  later  the  other  kidney 
will  be  affected.  The  difficulty  we  are  in,  is  in  determining  how  far  the 
disease  extends  in  a  particular  case. 

If  the  bladder  is  already  involved,  I  do  not  consider  anything  is  to  be 
gained  by  surgical  treatment  of  the  renal  disease.  If  it  is  not,  and  the 
renal  symptoms  are  of  comparatively  short  duration,  I  should  be  disposed 
to  recommend  an  exploratory  operation.  The  results  of  operative  treat- 
ment for  tuberculous  kidney,  so  far  reported  by  surgeons,  are  not  very 
encouraging,  probably  because  operation  has  been  put  off  till  too  late.     A 


436  GENERAL  DISEASES.  . 

mortality  of  27  to  40  per  cent,  has  been  recorded  from  nephrectomy,  and 
an  even  higher  rate  from  nephrotomy. 

In  tuberculosis  of  the  bladder,  tonic  and  hygienic  treatment  gives  the 
best  results.  Remedies  such  as  hyoscyamus,  liquor  potassse,  and  citrate 
of  potash  are  useful  in  relieving  irritability  and  frequency  of  micturition. 
I  have  seen  no  benefit,  but  rather  the  reverse,  from  iodoform  injections, 
the  use  of  which  has  been  advocated  by  some  surgeons.  Even  washing 
out  the  bladder  with  warm  boracic  lotion  (3  to  4  per  cent.)  sometimes 
seems  to  do  more  harm  than  good.  Surgical  treatment  is  only  called  for 
when  there  is  persistent  irritability  and  tenesmus.  To  relieve  these 
troublesome  symptoms,  suprapubic  cystotomy  has  been  performed,  and 
drainage  has  been  established  for  several  months.  The  rest  given  to  the 
part  in  this  way  acts  as  the  curative  agent,  and  great  relief  has  some- 
times been  afforded.  Scraping  of  the  ulcers,  or  other  active  treat- 
ment, is  difficult  to  carry  out  efficiently.  Attempts  have  been  made  to 
increase  the  capacity  of  the  bladder  by  gradual  distension  with  fluid. 

Testicle. 

Tuberculous  disease  of  the  testicle,  like  that  of  the  kidney,  is  frequently 
primary,  although  often  complicated  with  tubercle  in  other  organs.  As  a 
rule,  one  organ  only  is  affected.  Tubercle,  as  a  rule,  first  attacks  the  head 
of  the  epididymis,  although  some  authorities  hold  that  the  disease  most 
frequently  begins  in  the  globus  minor  or  tail.  The  disease,  however, 
wherever  it  may  begin,  soon  involves  the  whole  epididymis  in  the  form 
of  caseous  nodules,  which  may  soften  and  finally  discharge  externally,  the 
scrotum  previously  becoming  adherent.  The  disease  after  a  time  spreads 
into  the  testicle,  tubercles  appearing  first  in  the  corpus  Highmorianum. 
Caseous  nodules  may  also  be  found  in  the  body  of  the  testicle.  The  vas 
deferens  and  the  vesiculse  seminales  may  be  secondarily  involved,  and  lined 
with  caseous  material.  As  the  result  of  this,  the  vas  may  be  felt  to  be 
thickened.  The  prostate  also  is  likely  to  be  the  seat  of  caseous  deposit, 
being  similarly  affected,  consequent  on  tubercle  of  bladder  or  kidney. 
Sometimes  a  tuberculous  abscess  forms  in  it.  Tuberculous  testis  may 
occur  at  any  age.  Of  forty-six  cases  treated  at  St.  Thomas's  Hospital,  the 
ao;e  distribution  was  as  follows  : — 


-5 

-10 

-20 

-30 

-40 

-50 

8 

5 

4 

13 

9 

7 

Symptoms. — There  may  be  no  symptoms  apart  from  the  enlargement 
of  the  organ  and  the  inconvenience  of  a  sinus.  Probably  pain  only  occurs 
when  an  abscess  is  forming. 

Diagnosis  and.  prognosis. — The  diagnosis  has  to  be  made  from 
syphilitic  disease  and  new  growth.  Syphilis  attacks  the  body  of  the  testis, 
producing  a  painless,  smooth,  hard,  heavy,  uniform  swelling,  which  seldom 
breaks  down.  The  cord,  as  a  rule,  is  not  thickened.  With  syphilis, 
hydrocele  is  frequently  present;  with  tubercle,  it  is  uncommon.  New 
growth  usually  produces  a  solid,  smooth,  firm  enlargement  of  the  testicle, 
and  there  is  little  tendency  to  ulcerate  through  the  skin.  The  lumbar, 
and  sometimes  the  inguinal  glands,  are  secondarily  affected.  In  some 
cases  the  disease  becomes  arrested,  the  caseous  tubercle  becoming  en- 
capsuled  or  discharged.  There  is,  however,  a  strong  probability  that 
secondary  trouble  will  arise. 


TUBERCULOSIS.  437 

Treatment. — This  is  principally  a  question  for  the  surgeon.  Castra- 
tion or  epididyrnectomy  certainly  appears  to  be  indicated  where  the 
disease  is  localised.  Scraping  may  be  an  adequate  means  of  removing 
the  diseased  tissue  in  some  cases. 

Female  Generative  Organs. 

Tuberculosis  of  the  female  generative  organs  may  occur  at  any  age. 
It  is  usually  secondary  to  tuberculosis  elsewhere,  but  may  be  primary,  and 
be  followed  by  pulmonary  or  generalised  tuberculosis.  In  the  secondary 
cases  the  virus  is  conveyed  by  the  blood,  or  spreads  by  continuity  from 
neighbouring  organs.  The  primary  cases  may  result  from  direct  infection. 
It  is  difficult  to  obtain  direct  evidence  of  this  in  man.  That  tuberculosis 
of  the  female  genitals  may  be  so  produced  is  shown  by  certain  experiments 
on  animals.  The  introduction  of  cultures  of  bacilli  into  the  vagina  of 
guinea-pigs  has  been  followed  by  the  production  of  sub-epithelial  tubercles 
in  the  uterus.  Moreover,  guinea-pigs  and  rabbits  impregnated  by  males, 
into  whose  testicles  the  tuberculous  virus  had  been  previously  introduced, 
became  tuberculous  themselves,  with  pronounced  lesions  of  the  vagina  and 
uterus. 

"While  every  portion  of  the  genital  tract  may  be  affected,  the  most 
common  seat  of  the  disease  is  the  tubes.  Next  in  order  of  frequency  comes 
the  uterus,  then  the  ovaries,  vagina,  cervix,  and  vulva.  Both  tubes  are 
generally  involved,  although  sometimes  the  disease  is  limited  to  one. 

The  tubes  become  greatly  enlarged,  and  sink  behind  the  uterus,  forming 
large  sausage-shaped  tumours.  They  are  usually  adherent  to  the  surround- 
ing structures,  and  the  fimbriated  extremities  become  occluded.  The 
lumen  of  an  affected  tube  is  dilated,  and  the  interior  is  filled  with  yellow 
caseous  material,  which  may  be  of  pus-like  consistence,  or  hard  and  solid 
from  calcification.  It  is  often  impossible  to  distinguish  such  tubes  with 
the  naked  eye  from  those  of  ordinary  pyosalpinx.  Sometimes  a  tubal 
abscess  ruptures  into  the  bowel.  Infection  of  the  tubes  often  takes  place 
from  the  peritoneum.  They  are  found  to  be  tuberculous  in  from  30  to  50 
per  cent,  of  all  cases  of  tuberculous  peritonitis  in  women. 

In  the  uterus,  miliary  tubercle  may  be  found  situated  just  beneath  the 
epithelium.  A  chronic,  diffuse,  caseous  form  of  tuberculosis  is  much  more 
common.  The  entire  cavity  of  the  body  of  the  uterus  becomes  filled  with 
caseous  material.  The  underlying  tissue  may  be  studded  with  tubercles, 
or  irregularly  ulcerated.  Tubercles  gradually  form  in  the  muscular  tissue. 
As  a  rule,  the  cervical  canal  is  not  affected.  Rarely,  however,  it  is  the 
only  part  of  the  genital  tract  diseased.  Tubercle  of  the  ovaries  is  rare,  is 
always  secondary,  and  almost  invariably  is  part  of  a  general  disease.  The 
number  of  recorded  cases  is  small.  It  occurs  in  three  forms — (1)  Miliary 
tubercles  on  or  just  beneath  the  surface ;  (2)  caseous  deposits  in  the  sub- 
stance of  enlarged  or  cystic  ovaries ;  (3)  tuberculous  abscesses. 

Tuberculous  ulcers  are  rarely  observed  in  the  vagina.  When  they  occur 
they  are  generally  seated  on  the  posterior  wall,  and  are  usually  secondary 
to  tuberculosis  higher  up.  They  have  sharply-cut  margins,  and  shallow 
floors,  which  are  studded  with  granulations  and  covered  with  caseous 
material.  Shallow  ulcers  of  considerable  size,  with  granular  bases,  have 
been  observed  on  the  vulva  in  a  few  instances. 

Symptoms. — When  secondary,  the  disease  is  usually  quite  latent, 
and  not  revealed  by  any  symptoms.     This  is  sometimes  the  case  also  when 


438  GENERAL  DISEASES. 

the  disease  is  primary.  The  symptoms  are  never  characteristic,  and, 
according  to  Whitridge  Williams,  "  vary  from  those  of  simple  endometritis 
and  salpingitis  to  the  most  severe  forms  of  pelvic  abscess." 

Diagnosis. — The  discovery  of  the  bacillus  in  the  secretions,  or  of 
characteristic  tubercles  in  the  scrapings,  is  the  only  certain  means  of 
diagnosis.  The  rare  form  o,f  cervical  tuberculosis  is  very  likely  to  be  mis- 
taken for  malignant  disease,  and  foul  discharge  and  hemorrhage  may  occur 
in  one  as  well  as  in  the  other.  The  prognosis  is  always  grave,  on  account 
of  the  danger  of  tuberculous  disease  manifesting  itself  elsewhere,  especially 
tuberculous  peritonitis  and  pulmonary  phthisis. 

Treatment. — Ulcers  of  the  vagina,  cervix,  or  vulva  may  be  treated 
with  topical  applications,  such  as  lactic  acid,  iodised  phenol,  or  iodoform 
Tuberculosis  of  the  uterus  may  be  dealt  with  by  curetting  and  application 
of  iodoform.  In  case  of  recurrence,  vaginal  extirpation  of  the  uterus  and 
appendages  should  be  practised.  If  the  disease  is  limited  to  the  cervix, 
amputation  may  suffice.  For  tuberculosis  of  the  tubes  and  ovaries  their 
removal  by  laparotomy  is  indicated. 

The  Breast. 

In  many  cases  tuberculosis  of  the  breast  is  associated  with  other 
obvious  tuberculous  lesions.  Pregnancy,  lactation,  and  mastitis  are  the 
chief  predisposing  causes.  In  some  of  the  cases  there  has  been  a 
history  of  trauma.  Out  of  fifty-seven  cases  collected  by  Scudder,  only 
four  were  in  men.  Most  of  the  cases  occur  between  the  ages  of  20 
and  35. 

There  are  three  possible  modes  of  infection — (1)  direct  infection  from 
without ;  (2)  extension  by  contiguity ;  (3)  metastatic  tuberculosis,  hsema- 
togenic,  probably  the  most  common  form. 

The  disease  occurs  in  two  forms — (1)  disseminated  nodules ;  (2)  a 
confluent  mass.  The  first  form  is  much  the  rarer.  The  nodules  may  vary 
in  size  from  a  hazel-nut  to  a  walnut,  and  consist  of  caseous  masses,  with 
possibly  softening  centres.  In  the  second  form,  there  is  a  single  tumour. 
This  consists  of  a  mass — sometimes  hard,  ill-defined,  and  bossy,  sometimes 
more  or  less  soft.  It  usually  softens  at  the  centre,  and  discharges  through 
the  skin,  forming  one  or  more  fistulous  sinuses,  with  indurated  fungating 
edges.  The  discharge  may  contain  caseous  lumps.  On  section  of  such  a 
tumour,  there  is  found  to  be  an  irregular  cavity,  with  diverticula,  lined  by 
a  soft,  downy  membrane,  surrounded  by  indurated  greyish  white  tissue, 
containing  groups  of  little  opaque  or  semi-transparent  nodules,  with 
yellowish  centres,  or  one  or  two  larger  masses.  The  tuberculous  nodules 
develop  round  the  acini  and  small  ducts.  The  nodules  have  the  ordinary 
structure.  Giant  cells  are  usually  not  numerous.  Bacilli  have  been 
found  in  about  half  of  the  authentic  cases. 

Symptoms  are  not  very  characteristic.  Pain,  as  a  rule,  is  not  a 
marked  feature,  although  often  present  to  some  extent,  and  sometimes 
severe.  The  discovery  of  the  disease  is  often  accidental.  The  nipple  is 
rarely  retracted.  The  breast  is  usually  small  at  an  advanced  stage,  but 
in  early  cases  may  be  enlarged.  In  nearly  all  cases  the  axillary  glands 
are  involved. 

Diagnosis. — The  usual  association  of  the  disease  with  tubercle  else- 
where, the  features  of  the  tumour,  the  character  of  the  discharge  when 
there  is  a  sinus,  and  the  presence  of  bacilli  in  the  discharge,  or  the  result  of 


TUBERCULOSIS. 


439 


inoculation  in  guinea-pigs  in  doubtful  cases,  are  the  principal  points  which 
establish  a  diagnosis.     Carcinoma  is  often  with  difficulty  excluded. 

Prognosis. — If  the  disease  is  secondary,  its  presence  will  probably 
not  seriously  complicate  the  progress  of  disease  elsewhere.  When 
primary,  it  slowly  spreads  locally,  and  implicates  the  axillary  glands  and 
sets  up  tubercle  elsewhere. 

Treatment. — When  primary,  and  there  is  no  evidence  of  secondary 
deposit  in  the  internal  organs,  the  tumour  should  be  removed  along  with 
the  axillary  glands,  if  they  are  affected.  When  secondary,  it  is  a  question 
whether  it  should  be  left  alone  or  not.  Most  surgeons  are  inclined  not  to 
interfere. 


TUBEECULOSIS  OF  THE  INTEGUMENTAEY  SYSTEM. 

Tubercle,  as  it  affects  the  skin,  manifests  itself  under  several  distinct 
forms.  Of  these,  by  far  the  most  common  is  lupus  vulgaris.  The  other 
varieties  are  anatomical  tubercle,  verrucous  tubercle,  tuberculous  gumma, 
and  tuberculous  ulcer. 

Lupus  Vulgaris. 

The  now  recognised  position  of  lupus  as  a  tuberculous  disease  was  not 
established  until  the  discovery  of  the  tubercle  bacilli  in  the  lesions.  Virchow 
described  the  lupus  tissue  as  granulation  tissue  ;  Friedlander  showed  that 
it  possessed  all  the  histological  features  of  tubercle — giant  cells,  epithelioid 
cells,  and  lymphoid  cells ;  but  Koch  was  the  first,  we  believe,  to  demonstrate 
the  presence  of  bacilli. 

Etiology. — Bacilli  are  invariably  met  with  in  the  diseased  parts,  but 
they  are  extremely  few  in  number,  and  their  discovery  requires  great 
patience  and  the  examination  of  many  sections.  Among  perhaps  fifty 
sections  there  may  be  only  one  containing  one  or  two  bacilli.  The  bacilli 
are  found  in  the  interior  of,  or  in  close  proximity  to,  giant  cells.  They 
have  never  been  discovered  in  the  secretion  or  in  the  superficial  crusts. 
Fragments  of  lupus  tissue  sown  on  serum  have  given  rise  to  typical  cultures 
of  the  tubercle  bacillus.  Inoculation  experiments  on  animals  have  nearly 
always  succeeded,  when  the  inoculation  has  been  intraperitoneal,  and  a  large 
enough  fragment  has  been  employed.  The  paucity  of  the  bacilli  explains 
the  failure  of  some  observers  who  have  attempted  subcutaneous  inocula- 
tions with  minute  fragments.  It  is  unwarrantable  to  assume  that  the 
virulence  of  the  bacillus  is  in  any  way  attenuated. 

It  has  been  found  extremely  difficult,  if  not  impossible,  to  produce 
tuberculosis  in  guinea-pigs  and  rabbits  by  the  inoculation  of  superficial 
injuries  to  the  skin ;  but  the  conditions  of  the  skin  are  so  different  in  these 
animals,  from  those  in  the  human  being,  that  little  importance  can  be 
attached  to  this  experimental  fact.  The  situations  of  lupus  are  those 
where  inoculation  would  be  most  likely  to  occur.  A  few  cases  where 
typical  lupus  has  followed  inoculation  have  been  recorded.  The  lesions 
are  very  slow  in  their  evolution.  It  has  been  already  stated  that 
the  number  of  bacilli  is  extremely  small.  The  reason  of  this  is  probably 
that  the  skin  is  a  situation  little  favourable  to  the  growth  of  the  bacillus, 
on  account  of  the  close  structure  of  the  corium,  and  its  relatively  low  and 
variable  temperature. 

Lupus  abounds  in  populous  districts,  where  other  tuberculous  affections 


44°  GENERAL  DISEASES. 

flourish.  There  is  frequently  a  history  of  tubercle  among  the  parents  or 
other  relatives  of  lupus  patients.  The  disease  has  been  observed  in  both 
parent  and  child,  but  such  cases  are  exceptional,  and  there  is  nothing 
pointing  to  it  being  a  hereditary  affection. 

The  usual  time  of  onset  is  during  the  period  of  adolescence  or  early 
adult  life.  It  is  rare  in  infancy,  but  it  has  been  observed  at  the  age  of 
seven  months.  It  is  very  uncommon  in  later  adult  life.  Dr.  Payne 
mentions  as  exceptional  a  case  in  a  woman  of  59.  Women  are  more 
often  affected  than  men. 

A  few  cases  have  been  recorded  where  there  has  been  a  history  of 
tramna,  such  as  a  blow  from  a  cricket-ball.  There  are  also  recorded  cases 
of  its  occurrence  in  the  tracts  bored  for  earrings,  and  in  the  situation  of 
tattooage.     The  latter  have  been  cases  of  direct  inoculation. 

Association  with  other  forms  of  tuberculosis. —  The  glands  in 
relation  with  lupus  patches,  according  to  some  observers,  are  rarely 
affected;  according  to  others,  they  are  not  infrequently  so.  It  is  not 
uncommon  for  affection  of  the  glands  to  precede  lupus.  Payne  has 
stated  that,  in  his  experience,  antecedent  affection  of  the  glands  is  a 
frequent  if  not  usual  cause  of  lupus  under  the  lower  jaw.  Other  observers 
have  noted  the  frequency  of  lupus  about  the  fistulous  orifices  of  scrofulous 
abscesses.  Payne  found  that  about  one-fourth  of  his  patients  had  signs  of 
tubercle  elsewhere.  Other  observers  give  proportions  varying  from  a  fifth 
to  two-thirds. 

Morbid  anatomy. — The  characteristic  of  lupus  tissue  is  the  com- 
bination of  necrosis  with  fibrous  new  growth.  There  is  very  little  tendency 
to  caseation,  and  it  is  very  seldom  that  any  considerable  masses  of  caseous 
substance  are  met  with.  The  tissue  in  an  early  stage  may  be  seen  to  be 
composed  of  rounded  nodules,  discrete  or  confluent,  consisting  of  groups  of 
round  cells,  among  which  are  embedded  numerous  giant  cells  surrounded 
by  epithelioid  cells.  These  are  situated  in  the  vesicular  layer  of  the 
corium,  and  only  extend  to  the  upper  layers  when  there  is  a  tendency  to 
ulceration.  The  papillary  layer,  as  a  rule,  is  not  invaded  by  epithelioid  or 
giant  cells,  although  the  papillae  may  be  swollen  and  more  or  less  deformed 
and  infiltrated  with  young  cells.  The  epidermis  is,  as  a  rule,  thickened,  as 
regards  both  the  horny  layer  and  the  Malpighian  layer,  including  the 
prolongations  which  it  sends  between  the  papillae.  The  hypertrophy  of 
the  interpapillary  tissue  may  be  so  great  as  to  suggest  epithelioma.  In 
other  cases  the  epidermis  may  be  atrophied. 

Symptoms. — The  most  usual  situation  of  lupus  is  on  the  face,  par- 
ticularly the  cheeks  and  the  nose,  and  less  commonly  the  eyelids  or  the  lips. 
Next  in  frequency  come  the  extremities,  then  the  buttocks  and  the  trunk. 
The  neck  is  occasionally  affected,  and  very  exceptionally  the  hairy  scalp. 
The  mucous  membranes  adjacent  to  the  skin  are  sometimes  involved.  Of 
these,  the  nasal  mucous  membrane  is  the  most  commonly  affected,  next  the 
conjunctivae,  etc.  Most  usually  the  lesion  is  single,  and  it  is  always  so  at 
first.  Barely  there  are  multiple  foci.  In  exceptional  cases  as  many  as 
fifteen  lupus  patches  have  been  observed.  Multiple  patches  generally 
appear  early,  so  that,  if  a  single  patch  has  existed  long,  there  is  little 
likelihood  of  others  making  their  appearance.  The  affected  part  is  little 
painful  or  tender  to  pressure,  and  the  patient  is  as  a  rule  free  from  any 
symptoms.  The  lesion  generally  becomes  aggravated  in  cold  weather 
and  improves  in  summer.  Congestion  or  stagnation  of  the  circulation 
makes  it  worse.      The  disease  has   but   little   influence  on  the  general 


TUBERCULOSIS.  441 

health,  although  it  has  been  observed  that  lupus  patients  are  not  long 
lived.  The  most  characteristic  feature  of '  lupus,  as  observed  clinically, 
is  the  presence  of  little  nodules  about  the  size  of  a  pin's  head,  just 
beneath  the  epidermis.  These  nodules  have  a  reddish  or  brownish 
yellow  colour,  and  are  semi-transparent.  They  have  been  compared 
to  drops  of  apple-jelly  or  barley-sugar.  In  order  to  see  them  distinctly, 
it  is  sometimes  useful  to  remove  the  hyperemia  of  the  epidermis 
by  pressure  with  a  glass.  Although  they  can  be  plainly  felt  as  well  as 
seen,  they  are  soft,  and  a  needle  or  scarificator  will  pass  into  them  with 
extreme  ease.  The  nodules  may  be  isolated,  arranged  in  little  groups,  or 
they  may  be  confluent.  As  a  rule,  they  take  several  months  to  develop 
fully. 

The  affected  part  gradually  increases  in  size,  and  often  in  an  annular 
fashion.  While  spreading  at  the  periphery,  the  lesion  may  be  healing  at 
the  centre.  In  older  lesions,  such  nodules  as  have  just  been  described  are 
only  to  be  observed  at  the  periphery. 

The  skin  surrounding  the  affected  tissue  is  generally  slightly  swollen 
and  reddened  from  venous  congestion.  When  ulceration  occurs,  the 
nodules  caseate  and  soften,  and  migratory  cells  invade  the  corium.  The 
epidermis  exfoliates  and  ulcerates,  and  granulations  develop  on  the  floor. 
The  floor  secretes  scanty  thin  pus,  and  the  tubercles  become  covered  with 
scales,  crusts,  or  scabs.  Just  as  in  the  case  of  tubercle  elsewhere,  the 
fibrous  change  may  occur,  and  the  tubercles  gradually  be  transformed  into 
fibrous  cicatricial  tissue.  The  same  may  take  place  after  ulceration  has 
occurred.  As  the  result  of  this  cicatricial  contraction,  the  skin  may  be 
seamed  and  puckered  and  of  a  greyish  white  colour,  as  after  a  severe  burn, 
and  great  disfiguration  may  result. 

Lupus  is  extremely  chronic  in  its  course.  It  slowly  advances,  then 
becomes  arrested  or  recedes,  again  to  advance  once  more.  It  may  finally 
cease  to  be  active,  leaving  behind  it  cicatricial  tissue. 

Othek  Foems  of  Cutaneous  Tubeecle. 

Tuberculous  gummata  have  their  seat  in  the  corium  or  subcutaneous 
tissue,  and  are  covered  by  red  livid  skin.  They  grow  and,  forming  the 
so-called  cold  abscesses,  soften  or  ulcerate,  discharging  a  grumous,  purulent 
secretion.  They  sometimes  form  in  the  course  of  the  lymphatics.  The 
pus  contains  few  bacilli,  but  sets  up  tuberculosis  in  animals  on  inoculation. 

Anatomical  tubercle  first  appears  as  a  red  papule,  becoming  later  a  little 
pustule,  which  ulcerates  and  is  covered  with  a  yellowish  crust.  This 
gradually  takes  on  a  papillomatous  character.  Its  most  usual  position  is 
on  the  back  of  the  fingers,  hand,  or  forearm.  It  is  not  admitted  that  it  is 
always  tuberculous,  but  in  the  cases  proved  to  be  so  the  bacilli  have  been 
few  in  number,  which  may  explain  the  failure  to  find  them  in  other  cases. 
A  rare  form  has  been  described  by  Eiehl  and  Paltauf,  under  the  name 
of  verrucous  tubercle  of  the  skin.  This  affects  the  same  situations  as  the 
anatomical  tubercle.  It  has  been  observed  almost  exclusively  among  adults 
who  have  much  to  do  with  domestic  animals  or  their  products.  Unlike 
lupus,  the  lesion  is  situated  in  the  more  superficial  layers  of  the  cutis  vera, 
the  papillae  in  particular  being  the  seat  of  typical  tubercles.  Bacilli,  more- 
over, are  more  numerous  than  in  lupus.  The  lesions  consist  of  roundish 
plates,  from  the  size  of  a  pea  to  a  florin.  They  may  be  single  or  multiple. 
The  centre  is  a  projecting  warty  growth,  divided  by  fissures  and  covered 


442.  GENERAL  DISEASES. 

with  crusts.  About  this  warty  centre  are  numerous  little  superficial 
pustules,  surrounded  by  infiltrated  red  skin.  On  squeezing  the  growth,  pus 
exudes  from  innumerable  little  orifices.  The  lesion  is  slowly  progressive 
up  to  a  certain  point,  lasting  from  two  to  fifteen  years.  Like  lupus,  it 
may  undergo  cicatrisation. 

Tuberculous  ulcers  of  the  skin  are  most  frequent  near  the  various 
orifices,  mouth,  anus,  etc.  They  are  almost  always  observed  in  persons 
already  tuberculous,  resulting  from  auto-infection.  The  ulcers  are  round, 
oval,  or  serpiginous.  On  the  floor,  tuberculous  granulations  are  generally  to 
be  seen.  In  the  neighbourhood,  small  pustules  appear,  which  rupture  and 
give  rise  to  little  round  ulcers,  and  ultimately  become  continuous  with  the 
original  ulcer.  Bacilli  are  much  more  numerous  than  either  in  lupus  or 
in  the  verrucous  tubercle.  On  microscopical  examination,  typical  tubercles 
can  be  seen  in  the  derma. 

Treatment. — In  lupus,  as  in  all  forms  of  tubercle,  constitutional 
treatment  is  valuable.  Cod-liver  oil,  arsenic,  creosote,  etc.,  are  useful, 
while,  lately,  thyroid  gland  appears  to  have  been  given  with  benefit. 
Tuberculin,  both  in  the  old  and  the  new  form,  has  produced  temporary 
improvement,  but  does  not  appear  in  any  way  to  arrest  the  progress  of  the 
disease.  Local  treatment  has  proved  much  more  efficacious.  What  is 
aimed  at  by  local  treatment  is  the  destruction  of  the  diseased  tissue,  and 
the  removal  of  all  bacilli  The  mode  first  introduced  was  the  application 
of  caustics,  such  as  nitrate  of  silver,  or  caustic  potash.  Such  applications 
are  extremely  painful,  and  it  is  difficult  to  limit  their  effects  only  to  the 
diseased  tissue.  The  best  results  have  been  obtained  from  thorough  scraping, 
under  an  anaesthetic.  The  scraping  may  be  followed  by  the  application  of 
some  antiseptic,  such  as  pyrogallol  ointment  (10  per  cent.). 

According  to  Unna,  the  best  superficial  caustic  is  the  application 
of  his  salicylic  and  creosote  plaster  muslin,  which  may  be  obtained  in 
three  strengths,  and  in  his  experience  no  other  preparation  causes  such 
a  clean  excavation  of  the  lupus  nodule.  The  strongest  plaster  should  be 
used  in  the  first  instance,  and  may  be  kept  applied  for  a  week,  unless  there 
is  much  pain,  when  a  weaker  strength  should  be  employed.  Unna's  zinc 
ichthyol  salve  muslin  is  a  useful  dressing,  after  treatment  either  with 
pyrogallol  or  salicylic  acid  and  creosote.  In  all  deep  cases  a  caustic  is 
necessary,  and  Unna  prefers  the  chloride  of  antimony  for  the  purpose.  All 
the  nodules  should  be  touched  with  the  following  ointment : — Acid  salicyl., 
liq.  antimon.  chlorid.,  extr.  cannab.  indie,  of  each  1  part;  creosote,  2  parts; 
vaseline,  5  parts ;  lanoline,  10  parts.  In  older  cases,  with  scattered  nodules, 
double  strength  of  salicylic  acid,  chloride  of  antimony,  and  cannabis  indica 
may  be  employed.  Several  weeks  of  this  treatment  may  be  required. 
The  other  forms  of  cutaneous  tubercle  must  be  treated  on  similar  principles. 

The  light  treatment  recently  introduced  by  Finsen  of  Copenhagen, 
wherein,  by  means  of  special  apparatus,  the  chemical  rays  of  the  sun,  or 
electric  light  freed  from  the  heating  and  illuminating  rays,  are  brought 
to  bear  upon  the  diseased  tissue,  promises  to  be  of  great  benefit  if  not 
actually  curative  in  early  and  limited  cases. 

TUBEECULOSIS  OF  THE  NEBVOUS  SYSTEM. 

In  addition  to  the  acute  form,  tuberculous  meningitis,  already  discussed 
at  some  length,  we  meet  with  tubercle  in  two  chronic  forms — chronic 
meningitis ;  tuberculous  tumours. 


TUBER  C  UL  OSIS  443 

Chronic  Meningitis, 

This  is  decidedly  rare.  The  pia  mater  becomes  thickened  and  nodular, 
and  grey  fibrous  tubercles  are  adherent  to  its  surface  in  the  course  of  the 
vessels. 

Tuberculous  Tumours  of  the  Brain  and  Cord. 

Etiology. — These  are  usually  met  with  in  young  people,  four-fifths  of 
the  cases  occurring  under  the  age  of  15.  They  are  about  twice  as  common 
in  boys  as  in  girls.  They  are  generally  found  in  association  with  tubercle 
in  other  organs,  caseous  bronchial  glands,  etc.,  although  cases  are  sometimes 
met  with  where  a  tuberculous  tumour  is  the  only  lesion  present  in  the  body. 

Morbid  anatomy. — They  commonly  vary  in  size  from  a  pea  to  a 
walnut,  but  are  occasionally  much  larger.  Earely  they  have  been  found 
invading  the  whole  of  a  cerebellar  lobe.  They  are  rounded,  well-defined 
bodies,  firm  and  hard,  of  a  yellow  colour,  consisting  of  uniform,  opaque, 
cheesy  matter,  often  surrounded  with  a  softer  pinkish  grey  translucent  zone, 
in  which  sometimes  separate  tubercles  can  be  detected.  They  seldom  break 
down,  but  rarely  the  centre  has  been  diffluent.  Occasionally  they  have 
been  partially  calcified.  They  do  not  infiltrate  the  brain  substance  but 
compress  it,  and  so  cause  it  to  atrophy.  Sometimes  they  are  single,  but 
more  commonly  they  are  multiple.  As  many  as  twelve  tumours,  or  even 
more,  have  been  found  in  one  case. 

The  cerebellum  is  more  frequently  affected  than  any  other  part,  the 
cerebrum  next,  and  then  the  pons.  They  are  more  common  in  the  grey 
than  in  the  white  matter,  and  not  infrequently  abut  on  the  surface,  and 
become  attached  to  the  pia  mater  or  even  to  the  tentorium.  They  occa- 
sionally spring  from  the  dura  mater,  and  then  compress  the  surface  of  the 
brain  without  invading  it.  They  are  usually  of  slow  growth,  and  accord- 
ingly the  symptoms,  which  are  those  of  cerebral  tumour,  and  need  not 
be  specially  detailed  here,  come  on  very  gradually.  Occasionally  menin- 
gitis supervenes,  with  its  usual  symptoms. 

Tuberculous  tumours  of  the  cord  are  rare,  but  are  more  common  in  the 
upper  part  than  in  the  lower.  Occasionally  more  than  one  tumour  is 
present  in  the  substance  of  the  cord.  Tuberculous  tumours  growing  from 
the  dura-ma tral  sheath  are  still  more  rare.  Hale  White  has  recorded  a 
case  of  tuberculous  growth  between  the  dura  mater  and  the  upper  dorsal 
vertebrae. 

Diagnosis  and  prognosis. — Cerebral  tumour  in  the  adult  is  likely 
or  unlikely  to  be  tuberculous  according  as  signs  of  phthisis  are  present  or 
absent.  In  children,  evidences  of  tubercle  elsewhere  are  less  likely  to  be 
present,  and  we  must  be  guided  by  family  history,  situation  of  tumour,  etc. 
A  tumour  growing  rapidly  and  then  becoming  stationary  is  likely  to 
be  tuberculous.  The  duration  may  be  short  or  long,  a  few  weeks  or  a 
few  years.  Arrest  of  growth  of  a  tuberculous  cerebral  tumour  is  not  in- 
frequent, and  this  is  attended  with  relief  to  the  symptoms,  which,  as  far  as 
they  may  be  due  to  irritation  and  pressing,  subside  and  may  afterwards 
remain  stationary  for  a  long  time.  Lessening  of  the  headache  and  passing 
off  of  the  optic  neuritis  are  favourable  signs,  while  their  persistence  is 
unfavourable. 

Treatment. — When  we  suspect  the  tumour  to  be  tuberculous,  we 
should  endeavour  to  bring  about  arrest  by  treating  the  case  on  general 
principles,  with  good  food,  fresh  air,  etc. 

HECTOR  MACKENZIE. 


444    *  GENERAL  DISEASES. 


LEPEOSY. 

This  is  an  infective  disease  depending  on  the  presence  of  a  specific 
bacterium,  Bacillus  leprce,  in  the  tissues.  It  is  characterised  by  recurring 
febrile  attacks ;  macular  skin  eruptions ;  circumscribed  granulomatous  de- 
posits in  the  skin,  nerve  trunks,  and  viscera ;  and  by  secondary  ulcerations, 
local  anaesthesia,  and  trophic  changes.  It  runs  a  chronic  course,  and  is 
rarely  recovered  from. 

History  and  geographical  distribution. — It  is  believed  that 
leprosy  was  introduced  into  Europe  from  the  East,  vid  Egypt,  some  three 
or  four  hundred  years  before  the  Christian  era.  During  the  Middle  Ages 
it  overran  the  whole  of  the  Continent,  including  Britain,  and  was  probably 
more  common  in  Europe  at  that  time  than  it  is  anywhere,  even  in  the 
East,  at  the  present  day.  Presumably  in  consequence  of  compulsory  se- 
gregation and  isolation  of  the  affected,  and  of  the  hygienic  improvements 
coincident  with  advancing  civilisation,  leprosy  has  gradually,  during  the 
last  four  or  five  hundred  years,  diminished  in  Europe.  As  an  indigenous 
disease,  at  the  present  day,  it  is  quite  unknown  in  Britain  and  in  many 
other  European  countries.  It  still  lingers,  however,  in  certain  limited 
districts  in  Norway  and  throughout  the  countries  bordering  on  the 
Mediterranean.  It  is  also  found  in  one  or  two  places  in  Prance,  Germany, 
and  Eussia.  In  Asia,  Africa,  and  the  tropical  parts  of  America  it  is  still 
rife  enough.  Although  unequally  distributed  in  India,  it  is  computed  that 
in  that  country  at  the  present  day  there  are  over  100,000  lepers; 
in  China  the  number  is  probably  larger.  An  important  fact,  as  bearing 
on  the  question  of  infection,  is  the  circumstance  that  within  recent 
years  leprosy  has  invaded  countries  which  formerly  were  free  from  the 
disease. 

Etiology. — The  most  important  fact  in  the  etiology  of  leprosy  is 
the  presence  in  the  lepra  tissues  of  a  characteristic  bacillus.  This 
bacterium,  discovered  by  Hansen  in  1874,  in  its  morphological  and 
tinctorial  characters  closely  resembles  the  B.  tuberculosis.  It  differs, 
however,  in  one  important  particular:  up  to  the  present  it  has  resisted  all 
attempts  at  artificial  cultivation.  In  consequence  of  failure  in  this 
respect,  and  of  the  non-liability  of  the  lower  animals  to  leprosy,  the  proofs 
that  the  bacillus  is  the  cause  of  the  disease  with  which  it  is  uniformly, 
and,  so  far  as  known,  solely  connected,  have  not  been  established  by  the 
usual  methods,  and  are  to  that  extent  incomplete.  Nevertheless  the 
association  of  the  parasite  with  the  specific  lesions  is  so  intimate,  and  the 
analogy  between  leprosy  and  the  other  disease  mentioned — tuberculosis — 
so  close  in  other  respects,  that  there  can  be  little  doubt  that  B.leprce  and 
leprosy  are  related  to  each  other  as  cause  and  effect,  just  as  certainly  as 
that  B.  tuberculosis  is  so  related  to  tuberculosis.  If  this  be.  granted, 
it  follows  that  leprosy  is  a  germ  disease  and  therefore  communicable  and 
infectious.  The  facts  of  epidemiology  are  entirely  in  harmony  with  this 
conclusion.  Thus  leprosy  mostly  occurs  in  communities  in  which  personal 
and  domestic  cleanliness  are  grossly  neglected,  and  where  the  various 
members  of  the  community  and  their  fomites  are  in  frequent  and  close 
contact.  Moreover,  although  the  disease  runs  in  families,  it  appears  only 
in  those  members  who  remain  in  the  family  home,  and  not  in  those  who 
migrate  at  an  early  age  to,  or  who  have  been  born  and  lived  in,  non-leprous 
countries.    The  disease,  therefore,  is  not  hereditary,  as  was  concluded  at  one 


LEPROSY.  445 

time.  It  appears  in  families  because  the  various  members  living  under  the 
same  conditions  are  exposed  to  the  same  opportunities  of  infection.  These 
risks  may  be  inherited ;  not  so  the  bacillus.  Another  fact  pointing  to  the 
infectiveness  of  leprosy  is  the  gradual  diminution  of  the  disease  in  Norway 
since  the  isolation  and  segregation  of  lepers  has  been  systematically 
enforced  there.  Its  infective  nature  is  further  proved  by  the  eccentric 
spread  of  the  disease  from  foci ;  and  by  the  fact  that  in  recent  times  in 
the  Sandwich  Islands,  in  New  Caledonia,  and  in  other  places  previously 
exempt,  leprosy,  having  been  introduced  from  without,  is  now  extensively 
endemic.  Leprosy  is  not  a  powerfully  infective  disease.  Certainly  it  is 
less  so  than  tuberculosis ;  the  two  factors,  individual  receptiveness — 
possibly  to  some  extent  an  inherited  quality — and  the  presence  of  the 
bacillus,  concurring  less  frequently  than  in  the  latter  disease. 

Occupation,  social  condition  and  race,  seem  to  have  no  special  bearing 
on  liability  to  this  disease,  further  than  as  affecting  the  chances  of 
exposure  to  infection.  It  occurs  at  all  ages,  though,  from  the  great  length 
of  the  incubation  period,  it  is  necessarily  rare  in  infancy  and  early  child- 
hood. This  incubation  period  is  a  very  long  one;  its  exact  limits  are 
difficult  to  establish,  unless  in  very  exceptional  instances.  There  is  no 
primary  sore  by  which  the  date  of  infection  can  be  fixed  precisely.  Two 
or  three  years  may  be  stated  as  the  average  period ;  the  extremes  may  be 
put  at  three  months  and  thirty  years. 

Morbid  anatomy  and.  pathology. — The  pathological  element 
in  leprosy  is  the  leproma.  This  is  an  infiltration,  consisting  of  an  aggrega- 
tion of  small  cells,  either  in  the  deeper  layers  of  the  derma  or  in  the  nerves. 
In  the  ringed  eruption  presently  to  be  referred  to,  the  infiltration  is  more 
diffused  and  does  not  produce  a  definite  circumscribed  tumour. 

The  section  of  a  leproma  of  recent  origin  is  white,  glistening,  and  juicy ; 
if  more  mature,  it  has  a  brown  tinge.  The  cells  of  which  the  infiltration  is 
mainly  composed  contain  innumerable  bacilli ;  some  cells  three  or  four, 
others  many,  some  being  literally  crammed  with  the  parasites.  According 
to  Unna,  the  bacilli  may  be  found  free  in  the  lymph  spaces.  If  the  juice  of 
one  of  the  cutaneous  nodules  is  expressed  and  placed  on  a  slip  and  suitably 
stained,  the  bacilli  can  readily  be  made  out.  Examined  in  the  fresh  state, 
they  exhibit  considerable  activity.  In  the  older  lepromas,  globular,  dark 
masses,  known  as  "  globi,"  are  found.  They  give  the  brownish  tinge  to  the 
section,  and  are  believed  by  Hansen  to  be  made  up  of  the  remains  of 
degenerated  bacilli.  Leprotic  infiltration  occurs  in  the  liver,  spleen,  and, 
from  an  early  stage  of  the  disease,  in  the  testes.  The  macular  eruptions, 
the  prodromal  and  febrile  phenomena  of  leprosy,  are  to  be  explained  by 
the  presence  in  the  blood  of  a  bacillus-evolved  toxine ;  the  paretic  and 
trophic  lesions  in  nerve  leprosy  are  attributable  partly  to  nerve  degenera- 
tion caused  by  the  pressure  on  the  nerve  tubules  by  lepromatous  infiltra- 
tion in  the  neurolemma,  partly  also,  according  to  some  recent  investigations, 
to  leprotic  invasion  of  the  nerve  terminals. 

Symptoms. — In  the  majority  of  cases  there  is  a  distinct  prodromal 
stage,  lasting  for  weeks  or  months  or  even  for  years,  during  which  the 
patient  suffers  from  recurring  febrile  attacks,  headache,  languor,  depression, 
sleeplessness,  sometimes  profuse  perspirations,  neuralgia,  various  parses- 
thesiae,  rheumatic  pains,  and  so  forth.  In  a  few  instances  there  are  no 
prodromata. 

After  a  febrile  attack  of  greater  severity  than  usual,  a  macular 
eruption,  which  may  be  profuse,  or  which  may  be  limited  to  one  or  two 


446  GENERAL  DISEASES. 

spots,  appears.  The  maculae  vary  in  size,  in  shape,  and  in  colour  as  well 
as  in  number.  Generally  they  consist  of  very  slightly  raised  erythematous 
patches,  darker  in  the  centre,  and  shaded  off  at  the  periphery.  Sometimes 
they  are  pigmented ;  sometimes  they  are  vitiliginous ;  sometimes  they  are 
barely  half  an  inch  in  diameter ;  sometimes  they  are  larger  than  the  palm 
of  the  hand.  Sometimes  erythematous  patches  become  pigmented ;  or  they 
may  assume  a  ringed  appearance,  being  pale  and  somewhat  depressed  at  the 
centre  and  dark  red  at  the  narrow,  slightly  raised  ring  forming  the  peri- 
phery. The  earliest  spots  tend  to  disappear ;  but,  with  recurring  attacks 
of  fever  at  longer  or  shorter  intervals,  new  maculae  are  formed  which 
progressively  tend  to  become  more  permanent,  to  be  more  markedly 
anaesthetic,  more  pigmented,  or  more  vitiliginous.  The  hair  on  the  affected 
areas  falls  out,  and  the  sudoriparous  glands  become  atrophied. 

The  face,  particularly  the  superciliary  region,  is  a  favourite  situation 
for  the  macular  eruption ;  but  trunk  and  limbs  also  are  usually  more  or 
less  involved.  As  a  rule,  the  hands  and  feet  at  this  stage  are  exempt.  A 
curious  fact  is  that  the  hairy  scalp  never  becomes  the  seat  of  any  of  the 
specific  leprous  lesions,  either  early  or  late. 

After  a  longer  or  shorter  time,  the  disease  enters  on  a  further  stage, 
and  a  characteristic  granulomatous  growth  or  deposit — the  leproma — is 
formed  in  the  skin,  in  the  nerve  trunks,  or  in  both.  If  in  the  skin,  what  is 
known  as  nodular  (tuberculous)  leprosy ;  if  in  the  nerve  trunk,  what  is 
known  as  nerve  (anaesthetic)  leprosy ;  if  in  both,  mixed  leprosy  is  pro- 
duced. 

Nodular  leprosy. — In  this  the  prodromata  are  often  well  marked,  but 
the  macular  stage  may  be  slight  or  altogether  absent.  From  time  to  time, 
usually  accompanied  by  marked  febrile  movement,  purplish  (later  becom- 
ing brown)  thickenings  of  the  skin,  leading  to  pronounced  boss-like  nodules 
or  plaques,  appear.  These  thickenings,  which  are  firm,  rounded,  and 
involve  the  derma,  are  in  some  instances  more  or  less  permanent ;  in 
others,  after  a  time  they  may  be  absorbed ;  in  others  again  they  may 
ulcerate.  The  face,  ears,  neck,  arms,  hands,  thighs,  legs,  and  feet,  but 
especially  the  face,  are  favourite  situations  for  these  nodules.  In  the  case 
of  the  face,  when  the  thickening  is  of  great  extent,  the  features  are 
rendered  grotesque  and  repulsive  in  the  extreme.  The  skin  of  the  fore- 
head and  cheeks  is  thrown  into  heavy  folds,  and  the  nose  and  lips  are 
thickened  and  broadened  out.  This  appearance  is  appropriately  called 
"  leontiasis."  As  the  disease  progresses,  the  conjunctiva,  and  the  mucous 
membrane  of  the  nose,  of  the  mouth,  and  of  the  larynx,  are  also  involved. 
Destruction  of  the  cornea,  foetid  discharge  from  ulceration  of  the  nostrils, 
ulceration  about  the  mouth,  and  stenosis  of  the  larynx — one  or  all  of  them 
may  ensue.  Thus,  in  time,  the  patient  loses  the  senses  of  taste,  of  sight, 
and  of  smell,  and  speech  may  be  reduced  to  a  husky  whisper.  Later  on 
the  nerve  trunks  are  also  involved,  and  anaesthesia  and  trophic  changes 
similar  to  those  in  nerve  leprosy  ensue.  Ulcers  form  in  the  leprotic 
patches  on  the  limbs ;  fingers  and  toes  are  lost  from  atrophy  or  ulceration. 
There  may  also  be  swelling  of  the  abdomen  from  leprotic  deposit  in  the 
liver,  diarrhoea  from  amyloid  disease  of  the  bowel,  septic  conditions  from 
the  ulcerations.  Phthisis  may  ensue,  or  the  patient  may  die  from  slow 
exhaustion,  or  from  some  form  of  intercurrent  acute  disease.  Sexual 
power,  owing  to  nodular  deposits  in  the  testes,  is  early  lost. 

Nerve  leprosy. — The  characteristic  feature  of  this  type  is  the  deposit 
of  leprous  tissue  in  the  nerve  trunks,  leading   to  loss  of  function  and 


LEPROSY.  447 

secondary  trophic  or  inflammatory  changes  in  the  corresponding  nerve 
areas. 

After  the  prodromal  and  macular  stage,  well-marked  numbness  or 
muscular  weakness  of  a  hand  or  foot,  sometimes  preceded  or  accompanied  by 
severe  neuralgic  pains,  tingling,  and  other  parsesthesise,  generally  sets  in.  On 
examining  the  nerve  trunks  where  superficial,  or  where  they  lie  over  bones, 
particularly  the  ulnar  nerve  at  the  elbow,  firm  fusiform  thickening  is 
readily  made  out.  By  degrees  the  anaesthesia  in  the  implicated  area 
becomes  absolute,  the  muscular  wasting  complete.  Other  trophic  changes 
also  ensue;  the  hair  of  the  part  drops  out;  the  sweat  glands  atrophy; 
bullae  may  form ;  or  changes  in  the  pigmentation  may  supervene.  Ulcera- 
tions are  common,  particularly  in  the  hands,  feet,  fingers,  and  toes ;  per- 
forating ulcer  of  the  foot  is  frequently  seen.  The  fingers  and  toes  may 
perhaps  become  gangrenous,  or  the  phalanges  may  undergo  slow  interstitial 
absorption.  Deformities  from  loss  of  parts  or  from  muscular  atrophy  result. 
The  motor  and  sensory  nerves  of  the  face  may  be  similarly  affected,  the 
muscles  of  expression  becoming  atrophied  and  paralysed.  Thus  the  upper 
eyelid  may  droop,  the  lower  eyelid  become  everted,  and  the  eye  can  now  no 
longer  be  closed  or  moved.  As  a  consequence,  conjunctivitis  and,  later  on, 
cornification  of  the  conjunctiva  and  cornea  ensue.  The  muscles  about  the 
mouth  and  those  of  mastication  and  articulation  may  also  be  similarly 
affected;  the  saliva  then  dribbles  from  the  mouth,  chewing  and  deglutition 
are  difficult ;  speech  is  husky  and  inarticulate.  Ulceration  of  the  larynx  is 
common,  giving  rise  to  aphonia  and  difficult  breathing.  By  degrees 
the  functions  of  the  muscles  perish  one  after  another,  until  the  patient 
becomes  completely  helpless,  unable  to  move,  and  with  perhaps  only  one 
of  his  senses,  that  of  hearing,  intact.  Diarrhoea,  phthisis,  bronchitis,  or 
some  other  intercurrent  disease  may  supervene,  and  be  the  immediate 
cause  of  death. 

Mixed,  leprosy. — In  this,  nodulation  and  nerve  lesions  supervene  one 
on  the  other,  or  they  may  concur  from  the  onset. 

Diagnosis. — The  presence  of  well-marked  anaesthesia  in  a  skin  lesion 
is  distinctive  of  leprosy ;  equally  so  is  the  discovery  of  the  bacillus  in  the 
tissues,  expressed  juices,  or  discharges  of  a  cutaneous  thickening,  ulcera- 
tion, or  other  skin  lesion.  Falling  of  the  hair  and  absence  of  per- 
spiration in  an  anaesthetic  spot,  thickening  of  nerve  trunks  concurring  with 
skin  eruptions  and  trophic  lesions,  are  also  distinctive. 

Prognosis.— Nerve  leprosy  lasts  longer  than  the  nodular  form ;  the 
average  for  the  former  being  eighteen,  for  the  latter  eight  to  nine  years. 
Cases  of  the  nodular  variety  sometimes  run  their  course  in  one  or  two 
years.  Eecovery  from  leprosy  is  very  rare  indeed.  It  is  not  unusual  to 
see  nerve  leprosy  arrested  for  a  time,  and  the  disease  drawn  out  for  twenty 
or  thirty  years  even,  the  patient  dying  of  some  other  disease  before  the 
leprosy  can  be  said  to  have  run  its  course. 

Treatment. — The  hygienic  conditions  should  be  the  best  obtainable. 
Frequent  bathing,  warm  clothing,  good  food,  light  occupation,  a  dry, 
bracing  climate,  tonics,  cod-liver  oil,  and  everything  which  may  improve 
the  general  health,  should  be  had  recourse  to. 

In  the  treatment  of  leprosy,  many  drugs  have  been  employed  in  the 
hope  that  they  possess  a  specific  influence  on  the  disease.  A  genuine 
specific  has  yet  to  be  discovered.  Chaulmugra  oil  {oleum  gynocardium),  in 
doses  of  from  two  up  to  forty  drops,  according  to  tolerance,  three  times  a 
day,  in   capsules  or  emulsion,  is  a  favourite  drug  in  English  practice. 


448  GENERAL  DISEASES. 

Unna  gives  ichthyol  internally  in  increasing  doses,  treating  the  surface 
lesions  at  the  same  time  with  pyrogallic  acid  (10  per  cent.),  or  chryso- 
phanic  acid  (10  per  cent.)  in  lanoline  ointment.  Crocker  has  recently 
recorded  two  encouraging  cases  treated  by  hypodermic  injections  of 
one-fifth  of  a  grain  of  mercury  bichloride,  administered  at  suitable 
intervals.  Danielsen  gives  the  salicylates  in  increasing  doses,  four  times  a 
day,  beginning  with  15  grs.,  for  six  months  or  a  year,  and  claims 
that  this  treatment  is  effective  if  instituted  in  the  early  stages. 

Lepers  ought  not  to  be  allowed  to  mix  freely  with  the  general 
population,  more  especially  during  the  ulcerative  stages  of  the  disease. 
To  any  given  individual  the  risk  of  infection  is  small,  but  the  chance  of 
some  individual  in  the  community  becoming  infected  by  a  leper  associating 
freely  with  its  members  is  considerable.  A  system  of  isolation  and  segre- 
gation— such  as  is  practised  in  Norway — in  which  the  rights  of  the  leper  as  a 
human  being  are  not  altogether  sacrificed  to  the  interests  of  the  rest  of  the 
population,  is  not  only  from  an  ethical  standpoint  the  right  system,  but 
practically,  since  it  is  not  repellant  and  so  does  not  lead  to  concealment,  is 
the  best  and  most  effective. 

In  vaccinating  children  in  leprous  countries,  great  care  should  be 
exercised  in  selecting  a  vaccinifer  free  from  the  slightest  suspicion  of 
leprosy.  Similarly,  in  such  countries,  care  should  be  exercised  in  the 
selection  of  wet  nurses  and  domestic  servants. 

PATRICK  HANSON. 


ACTINOMYCOSIS. 


A  specific  infective  disease,  due  to  the  presence  in  the  system  of  the 
ray  fungus,  or  Actinomyces  hovis,  and  attended  by  the  formation  of  chronic 
abscesses,  or  tumour  formations  of  granulation  tissue. 

History. — This  disease  was  first  recognised  as  having  a  parasitic 
origin  in  cattle,  by  Bollinger,  in  1876.  It  occurs  most  frequently  in  oxen, 
where  it  gives  rise  to  what  is  known  as  "  wooden  tongue  " ;  but  also  affects 
swine  and  other  animals.  Since  attention  has  been  directed  to  the  subject, 
a  considerable  number  of  cases  have  been  observed  in  the  human  subject, 
by  Israel  and  others. 

Etiology. — The  disease  is  undoubtedly  due  to  a  parasitic  fungus, 
which  is  usually  regarded  as  a  species  of  cladothrix ;  but  its  exact 
botanical  position  and  life-history  have  not  yet  been  properly  worked  out. 
Great  difficulty  was  at  first  experienced  in  cultivating  the  organism,  and 
when  this  was  accomplished  its  appearance  in  artificial  cultivations  was  so 
different  from  that  in  the  animal  body,  that  doubt  arose  as  to  whether  it 
was  the  same  organism.  The  disease  does  not  appear  to  be  usually  con- 
tracted from  other  cases  of  the  infection,  either  in  man  or  animals ;  but 
both  man  and  animals  appear  to  be  infected  from  the  same  source  and  in 
the  same  manner,  probably  by  means  of  certain  varieties  of  grain' on  which 
the  fungus  grows.  The  disease  is  usually  localised  in,  and  is  acquired 
through,  the  respiratory  or  alimentary  tract. 

The  organism,  as  found  in  the  tissues,  consists  of  a  series  of  short 
threads  arranged  in  a  radiating  manner,  many  springing  from  a  common 
centre.  It  is  from  this  radiating  arrangement  that  the  fungus  has  been 
called  the  ray  fungus,  or  actinomyces.     The  individual  clumps  are  of  small 


A  CTINOMYCOSIS. 


449 


size,  and  not  visible  to  the  naked  eye  ;  but  are  usually  united  into  larger 
masses,  and  form  small  yellow-coloured  granules  in  the  discharges  and  new 
formations,  which  form  a  characteristic  indication  of  the  disease.  The 
organism  may  be  most  easily  recognised  by  staining  with  gentian-violet, 
according  to  Gram's  method. 

Morbid  anatomy  and.  pathology. — The  organism,  wherever 
deposited,  gives  rise  to  irritation  of  the  tissues,  which  is  followed  by  small- 
celled  infiltration,  accompanied  not  unusually  by  the  formation  of  giant 
cells.  The  character  of  the  process  appears  to  depend  on  the  local  resist- 
ance of  the  tissues,  and  probably  also  on  the  nature  of  the  infecting 
organism.  Where  the  resistance  is  great,  inflammatory  reaction  occurs  in 
the  neighbourhood  of  the  new  formation,  and  this  tends  to  develop  into 
connective  tissue,  especially  at  the  periphery,  and  thus  arrest  the  further 
progress  of  the  disease.  Where  the  tissues  are  more  susceptible,  the  small- 
celled  infiltration  spreads  rapidly,  the  tissues  undergoing  necrosis.  There 
is  no  tendency  to  develop  granulation  tissue,  nor  to  form  a  bounding  zone 
of  connective  tissue,  although  the  parts  first  affected  form  finally  dense 
scar  tissue.  The  tissues  affected  ultimately  undergo  fatty  degeneration 
and  liquefaction,  with  the  formation  usually  of  creamy  pus,  in  which  the 
characteristic  organisms  are  to  be  found. 

Symptoms.  —  The  symptoms  resulting  from  the  development  of 
actinomycosis  are  those  which  attend  on  the  formation  of  a  chronic 
tumour,  which  ultimately  bursts  in  the  direction  of  least  resistance,  and 
discharges  its  contents,  and  then  tends  to  cicatrise.  This  is  usually  accom- 
panied by  little  pain  or  constitutional  disturbance,  owing,  no  doubt,  to  the 
chronic  character  of  the  process.  The  symptoms  may,  however,  be  much 
more  acute,  and  simulate  pyaemia,  which  may  be  ascribed  to  the  entrance 
of  pyogenic  organisms. 

When  the  jaw  or  pharynx  is  affected,  the  tumour  gives  rise  to  those 
symptoms  due  to  its  mechanical  interference  with  the  tissues  involved. 
The  disease  may  spread  to  the  thoracic  or  abdominal  organs,  or  may  even, 
primarily  affect  these,  and  in  each  case  gives  rise  to  its  appropriate 
symptoms. 

Diagnosis  and  prognosis. — The  diagnosis  must  depend  upon  the 
chronicity  of  the  affection,  and  the  discovery,  if  possible,  of  the  character- 
istic organism  in  the  discharges.  It  may  be  distinguished  from  a  sarcoma 
frequently  by  the  fact  that  the  enlargement  of  the  lymphatic  glands  is 
usually  absent.  The  disease  is  sometimes  very  chronic,  and  where  it  can 
be  extirpated  surgically  the  prognosis  is  good.  Spontaneous  recovery  has 
not,  however,  been  observed. 

Treatment. — The  only  treatment  available  till  quite  recently  was 
that  of  extirpation  by  the  knife  or  sharp  spoon,  but  the  very  favourable 
results  obtained  by  the  use  of  iodide  of  potassium  in  cases  of  this  disease  in 
cattle,  warrant  us  in  expecting  similar  results  in  the  human  subject.  It 
should  be  noted,  however,  that  the  character  of  the  tissue  reaction  in  the 
human  subject  would  suggest  that  in  this  case  the  disease  is  more  virulent 
than  in  the  case  of  animals,  and  that  accordingly,  perhaps,  less  marked 
results  may  be  expected  from  this  treatment. 

G.  E.  CART  WEIGHT  WOOD. 


VOL.  I. 29 


45o  GENERAL  DISEASES. 


HYDEOPHOBIA— EABIES. 

An  acute  specific  disease,  the  causal  agent  of  which  is  still  unknown, 
which  affects  chiefly  the  central  nervous  system,  and  wh'ich  was,  until  the 
introduction  of  the  Pasteur  treatment,  almost  invariably  fatal. 

History. — The  microbe  associated  with  this  disease  has  not  yet  been 
isolated ;  but  as  it  comports  itself  in  all  respects  like  one  due  to  a  living 
organism,  there  can  be  no  question  as  to  its  causation.  Pasteur's  experi- 
ments, which  showed  that  the  virus  might  be  intensified  by  passage  through 
certain  species  of  animals,  and  attenuated  by  inoculation  into  another 
species,  and  that  annuals  can  by  a  process  of  vaccination  be  rendered 
insusceptible  to  the  most  deadly  form  of  inoculation,  established  definitely 
that  the  disease  was  due  to  a  living  microbe.  Although  unable  to  demon- 
strate the  cause  of  the  disease,  Pasteur  continued  his  investigations,  in  hopes 
of  discovering  a  method  of  curing  the  disease,  and  in  1885  employed  his 
process  on  Joseph  Meister  with  a  successful  result.  The  treatment  consists 
in  the  subcutaneous  injection  of  emulsions  of  the  spinal  cords  of  rabbits 
which  have  been  killed  with  the  most  intense  virus  of  rabies.  It  had  been 
found  that  when  the  spinal  cord  was  retained  in  a  dry  atmosphere,  at 
22°  C,  for  fourteen  days,  it  had  become  quite  inactive ;  while,  when 
exposed  for  shorter  periods,  the  virus  was  correspondingly  more  active. 
The  first  injections  consist  of  emulsions,  which  have  been  exposed  for 
fourteen  days,  but  those  of  more  recent  date  are  afterwards  employed  until 
a  virus  which  has  been  treated  for  only  three  days  is  used  for  the  emulsions. 
The  amount  introduced,  and  the  rapidity  with  which  the  cords  of  different 
strengths  are  made  use  of,  are  varied  according  to  the  character  of  the  case 
under  treatment.  The  success  of  this  treatment  in  the  case  of  rabies 
depends  on  the  fact,  first,  that  the  disease  has  a  long  incubation  period; 
secondly,  that  we  are  able  to  recognise  the  probability  of  inoculation  of  the 
disease  at  the  time  of  its  occurrence.  Under  these  conditions,  we  anticipate 
the  development  of  the  disease  by  inducing  a  condition  of  immunity  or 
greater  resistance  of  the  tissues  by  the  introduction  of  the  specific  products 
of  the  virus.  The  immunity  thus  induced  is  only  a  relative  one  ;  so  that 
the  potential  resistance  of  the  tissues  is  increased  to  such  an  extent  that 
the  virus  originally  introduced  acts  now  merely  as  a  vaccine,  inducing  in  a 
successful  case  of  treatment  little  or  no  disturbance  of  the  general  health. 
This  is  indicated  by  the  fact  that  the  cases  where  the  treatment  has  failed 
have  been  cases  brought  under  treatment  at  a  late  stage,  or  those  resulting 
from  the  worst  species  of  bites,  such  as  those  occurring  on  the  face  and 
caused  by  wolves.  It  has  been  experimentally  shown,  for  many  bacterial 
diseases,  that  the  introduction  of  a  vaccine  exerts  no  influence  on  a  disease 
which  has  already  begun  to  manifest  itself,  and  that  frequently  the  disease 
is  even  more  deadly  than  normal,  unless  a  certain  definite  period  has  been 
allowed  to  elapse  between  the  process  of  vaccination  and  the  control 
inoculation  of  the  virulent  virus.  We  can  thus  understand  that,  where  too 
short  a  period  for  the  induction  of  immunity  elapses  between  the  injections 
and  development  of  the  disease,  to  allow  of  the  acquired  tolerance  of  the 
tissues  keeping  pace  with  the  advance  of  the  disease,  the  virus  no  longer 
manifests  itself  as  a  vaccine,  but  develops  the  usual  symptoms  of  the 
disease,  probably  almost  uninfluenced  by  the  treatment  to  which  the 
patient  has  been  subjected.  In  addition  to  the  Pasteur  treatment,  more 
recently  a  method  analogous  to  that  introduced  by  Behring  for  diphtheria 


HYDROPHOBIA— RABIES.  451 

and  tetanus,  in  which  antitoxic  serums  are  used  to  antagonise  the  virus, 
has  been  suggested,  in  which  antirabic  serum  is  used  to  combat  the  disease  ; 
hut  the  results  at  present  to  hand  must  be  regarded  as  entirely  tentative. 

Etiology. — This  disease  is  in  man  invariably  the  result  of  inocula- 
tion with  the  poison  of  rabid  animals,  which  commonly  occurs  as  the  result 
of  a  bite.  In  most  cases  this  disease  is  contracted  from  dogs,  but  cats, 
wolves,  and  foxes  may  also  transmit  the  disease ;  it  has  even  been  con- 
tracted from  the  infection  of  a  wound  acquired  during  the  dissection  of  a 
rabid  animal.  Other  animals,  such  as  cows,  deer,  and  horses,  may  become 
rabid,  but  are  not  of  importance  as  regards  setting  up  the  disease  in  the 
human  subject.  Statistics  seem  to  show  that  bites  from  the  wolf  and  the 
cat  are  more  dangerous  than  those  from  the  dog,  and  this  appears  to  be  due 
to  the  poison  being  more  active  in  these  animals,  but  may  also  be  attributed 
to  the  bites  in  these  cases  being  more  severe  and  frequently  multiple.  The 
saliva  is  the  only  secretion  in  which  it  has  been  proved  that  the  poison  is 
present.  Only  a  certain  proportion  of  those  bitten  by  a  rabid  animal  are 
affected  by  the  disease ;  and  although  the  figures  quoted  on  the  point  vary 
greatly,  it  is  probable  that  at  least  two-thirds  of  those  exposed  to  the 
infection  may  escape.  In  this  respect,  however,  the  locality  of  the  bite  and 
its  extent  and  depth  exert  great  influence ;  thus  a  bite  incurred  through 
the  clothing  is  probably  much  less  deadly,  owing  to  most  of  the  virus  being 
wiped  off  the  teeth,  which  would  account  for  the  relative  greater  danger 
from  wounds  on  the  uncovered  parts,  such  as  the  face  and  hands.  There 
seems,  however,  no  doubt  that  bites  on  the  face  are  not  merely  more  apt  to 
give  rise  to  the  disease,  but  are,  as  a  rule,  more  acute.  This  has  been 
ascribed  to  the  fact  that,  as  the  virus  travels  along  the  nerve  trunk  to  the 
central  nervous  system,  in  the  case  of  the  face  the  path  is  much  shorter 
than  where  one  of  the  extremities  has  been  the  site  of  inoculation.  Where 
the  bites  are  multiple,  the  probability  of  infection,  and  of  an  acute  type,  are 
naturally  increased. 

The  usual  period  of  incubation  in  the  human  subject  is  six  or  seven 
weeks,  but,  on  the  other  hand,  cases  have  been  recorded  where  symptoms 
have  supervened  within  a  week,  while  they  may  not  develop  till  as  late  as 
two  years  (Horsley).  These  variations  are  no  doubt  to  be  accounted  for 
by  the  amount  of  the  virus  originally  introduced,  its  activity,  the  nature 
and  extent  of  the  wound,  and  the  susceptibility  of  the  individual 
affected. 

Morbid  anatomy  and  pathology.  —  The  morbid  changes 
observed  consist  practically  of  evidences  of  hyperemia  and  congestion  in 
the  central  nervous  system.  In  special  places,  local  congestion  with 
migration  of  leucocytes  into  the  perivascular  lymphatic  spaces  and  the 
interstitial  neuroglia,  along  with  slight  extravasations  of  blood,  may  be 
observed.  These  are  said  to  be  found  chiefly  in  the  neighbourhood  of  the 
medulla  oblongata.  Congestion  and  sometimes  even  haemorrhages  from 
the  mucous  membranes  may  also  be  .found  in  the  fauces,  pharynx, 
oesophagus,  and  stomach. 

Symptoms.  —  The  wound  usually  heals  without  developing  any 
unusual  symptoms,  and  the  general  health  remains  apparently  unim- 
paired during  the  period  of  incubation.  Occasionally  the  wound  be- 
comes irritated,  or  even  undergoes  inflammation,  as  the  acute  symptoms 
set  in.  The  earliest  symptoms  are  usually  malaise,  disturbed  sleep,  and  a 
difficulty  in  swallowing  fluids.  The  pulse  is  quickened,  sometimes  becom- 
ing very  rapid,  and  the  respirations  are  hurried  and  shallow,  and  these 


452  GENERAL  DISEASES. 

symptoms  are  succeeded  by  a  general  hyperesthesia.  As  the  disease 
progresses  these  symptoms  become  much  more  marked.  The  patient 
suffers  from  great  mental  excitement  and  even  from  hallucinations.  The 
mouth  and  fauces  become  congested,  and  the  patient  ejects  with  great 
difficulty  and  much  noise  thick  tenacious  mucus.  The  attempt  to  swallow 
is  attended  with  the  greatest  agitation,  which  induces  spasmodic  contraction 
of  the  muscles  of  deglutition,  followed  by  contraction  of  the  respiratory  and 
abdominal  muscles,  in  consequence  of  which  the  respiration  is  suspended, 
and  the  patient  may  die  from  syncope  during  one  of  these  attacks.  The 
spasms  of  the  muscles  may  then  become  general  and  convulsive  in 
character,  and  excited  by  the  slighest  external  cause.  The  patient  usually 
succumbs  finally  to  exhaustion,  and  does  not  exhibit  the  typical  paralytic 
stage  exhibited  in  the  dog  and  other  animals. 

Diagnosis. — In  the  recognition  of  the  disease,  the  history  of  the  case 
as  regards  the  condition  and  source  of  the  bite  are  usually  sufficient  to 
clear  up  any  doubts.  The  early  symptoms  may  be  stimulated  by  mere 
hysteria,  but  the  untypical  character  of  the  respiratory  symptoms  usually 
suffices  to  distinguish  in  these  cases.  This  disease  has  sometimes  been 
confounded  with  tetanus,  which  may  also  occur  as  the  result  of  a  bite,  but 
the  much  shorter  incubation  period  of  the  latter,  the  character  of  the 
spasm,  and  the  absence  of  the  mental  anxiety  present  in  the  former 
disease,  suffice  to  distinguish  them. 

In  consideration  of  the  anxiety  to  which  a  person  bitten  may  be 
exposed,  owing  to  the  long  period  of  incubation  which  may  supervene 
before  symptoms  develop,  it  is  desirable  that,  wherever  a  person  has  been 
bitten  by  an  animal  suspected  to  be  suffering  from  rabies,  that  the  question 
should  be  definitely  settled  by  the  inoculation  of  animals.  This  is  done  by 
inoculating  a  rabbit  under  the  dura  mater  with  a  small  proportion  of  the 
medulla  of  the  suspected  animal,  when,  in  the  course  of  two  or  three  weeks, 
the  animal  should  evince  symptoms  of  paralysis,  forming  what  is  known 
as  dumb  rabies.  In  the  case  of  negative  result,  all  anxiety  as  regards  the 
consequence  of  the  bite  are  at  once  obviated. 

Prognosis. — Hydrophobia  was  practically  a  fatal  disease  until  the 
introduction  of  the  Pasteur  treatment,  but  where  this  has  been  commenced 
within  six  days  of  the  bite  the  prevention  of  the  disease  is  practically 
certain.  The  later  the  period  after  the  inoculation  of  the  virus  that  the 
patient  is  brought  under  the  treatment,  the  less  certain  is  the  result.  It 
must  also  be  borne  in  mind  that  bites  on  the  head,  or  those  acqiured  from 
cats  or  wolves,  where  the  poison  is  more  virulent,  are  much  more  danger- 
ous and  less  susceptible  to  Pasteur's  treatment  than  others. 

Treatment. — Prophylaxis. — Until  recently,  our  only  method  of  com- 
bating the  disease  was  to  stamp  out  or  prevent  the  spread  of  infection  in 
dogs,  from  whom  the  disease  is  usually  contracted  in  this  country.  This 
was  done  (1)  by  muzzling  all  dogs,  and  (2)  by  destruction  of  all  owner- 
less dogs.  The  enforcement  of  this  regulation  produced  a  steadily  decreas- 
ing number  of  cases,  but  on  the  relaxation  of  the  order  the  figures  then 
began  to  rise  slowly  but  steadily,  until  it  was  again  enforced.  This 
indicated  quite  clearly  that  the  disease  might  be  probably  practically 
extirpated,  if  proper  care  were  exercised  for  a  sufficient  period  of  time. 

Local  treatment. — The  wound  may  be  treated  with  strong  carbolic 
acid,  and  then,  if  possible,  excised ;  but  these  surgical  measures  cannot  how- 
ever be  relied  upon. 

Pasteur  treatment. — In  every  case  where  a  patient  has  been  bitten 


ANTHRAX.  453 

by  a  dog,  which  there  are  good  reasons  to  suspect  of  being  rabid,  recourse 
should  be  had  to  this  treatment,  since  it  has  been  shown  that  a  previous 
mortality  of  15  per  cent,  has  been  reduced  by  its  means  to  less  than  1  per 
cent.  Where  the  disease  has  already  manifested  itself,  we  can  only  alleviate 
the  symptoms  by  having  recourse  to  large  doses  of  powerful  narcotics. 

G.  E.  CARTWRIGHT  WOOD. 


ANTHRAX. 


An  acute  specific  infective  disease,  due  to  the  introduction  and  multi- 
plication of  the  Bacillus  anthracis  in  the  system. 

History. — It  is  one  of  the  most  fatal  and  widespread  diseases  which 
affect  cattle,  occurring  frequently,  as  it  does,  in  both  the  New  and  the  Old 
Worlds,  where  it  is  known  as  splenic  fever,  from  this  organ  being  as  a  rule 
markedly  affected.  Among  the  domesticated  animals  usually  affected  are 
horned  cattle,  horses,  sheep,  and  swine.  It  may  be  said,  indeed,  generally, 
that  the  Herbivora  are  susceptible,  while,  on  the  other  hand,  the  Carnivora 
are  as  a  rule  more  refractory;  thus  many  wild  animals,  such  as  deer, 
buffaloes,  camels,  and  elephants,  are  subject  to  the  disease.  This  disease  is 
of  special  interest  to  us,  as  it  was  the  first  disease  in  which  a  microbe,  as 
a  causal  agent,  was  definitely  demonstrated,  and  in  which,  still  later,  the 
possibility  of  attenuating  the  microbe,  so  that  it  might  be  used  as  a  vaccine 
to  protect  against  subsequent  infection  with  the  disease  organism,  was 
first  established.  Indeed,  most  of  the  important  advances  in  our  know- 
ledge of  bacteria  were  made  by  investigations  carried  out  with  this  organism. 
As  early  as  1849,  Pollender  observed  the  occurrence  of  short  rods  in  the 
blood  of  animals  which  had  succumbed  to  the  disease ;  the  relation  of  these 
rods  to  the  disease  was,  however,  only  established  much  later  by  Davaine 
and  Pasteur.  To  Koch,  however,  the  credit  is  due  of  furnishing  the  com- 
plete proof,  by  cultivating  the  organism  on  artificial  media,  and  infecting 
susceptible  animals  from  cultures  which  had  been  carried  on  for  many 
generations  outside  the  animal  body.  He  was  also  able  to  work  out  in 
great  part  the  life-history  of  the  bacillus  and  its  relation  to  the  disease. 

The  organism  consists  of  rods,  usually  about  1  p  in  breadth,  and  varying 
extremely  in  length,  from  short  rods  (3  fi)  to  long  filaments  (20  p). 
These  rods  are  easily  destroyed  by  heat,  antiseptics,  and  many  conditions 
— such  as  drying — to  which  they  are  naturally  exposed  in  nature,  so  that 
one  might  expect  that  the  disease  would  tend  to  disappear.  Koch  was 
able  to  show,  however,  that  under  favourable  conditions  very  resistant 
.spores  were  formed,  and  that  these  are,  at  any  rate  usually,  the  origin  of 
the  disease  in  cattle,  which  is  the  result  of  the  ingestion  of  the  spores  in 
the  food,  the  bacilli  themselves  being  unable  to  effect  this,  owing  probably 
to  the  antiseptic  action  exerted  by  the  gastric  juice.  These  spores,  how- 
ever, are  only  produced  under  certain  special  conditions  of  temperature 
and  presence  of  oxygen.  They  do  not  appear  to  be  usually  formed  at  a 
temperature  lower  than  24°  C.,  and  only  then  under  conditions  which 
permit  of  free  access  of  oxygen.  Spores  are  never  formed  within  the 
animal  body,  so  that  the  disease  is  usually  spread  by  the  discharges  from 
the  intestine  and  bladder  giving  rise  to  the  formation  of  spores  after  being 
evacuated  where  the  external  conditions,  especially  those  of  temperature, 


454  GENERAL  DISEASES. 

are  favourable.  If  the  animal,  however,  is  opened,  the  blood  which  is  shed 
and  the  organs  which  are  exposed  to  the  air,  should  they  contain  the 
bacilli,  under  favourable  conditions  rapidly  gives  rise  to  spores.  We  can 
in  this  way  readily  understand  how  a  locality  where  a  case  of  anthrax  has 
occurred,  may  become  infected  with  the  spores,  and  in  this  way  the  disease 
remain  endemic  and  continue  to  give  rise  to  the  disease  for  a  long  period 
of  time.  The  influence  of  temperature  in  allowing  the  disease  to  become 
endemic  is  shown  by  the  fact  that  it  occurs  in  this  form  in  France, 
Germany,  Austria,  and  Eussia,  whilst  in  Britain  in  most  cases  the  germs 
seem  usually  to  have  been  imported  either  with  fodder  or  on  dried  hides. 

The  symptoms  occurring  in  this  disease  were  at  one  time  ascribed  to 
the  mechanical  influence  exerted  by  the  presence  of  the  bacilli,  and  even  to 
their  producing  directly  a  form  of  asphyxia,  but  these  are  now  by  common 
consent  ascribed  to  the  toxic  products  secreted  by  the  organism.  By  culti- 
vation of  the  organism  in  broth  containing  fibrin,  E.  H.  Hankin  obtained 
an  albumose  which  was  able  to  confer  immunity  upon  animals  against 
subsequent  inoculation  with  the  living  organism.  Almost  simultaneously 
Sidney  Martin  showed  that  the  Bacillus  anthracis,  as  the  result  of  its- 
growth  on  alkali  albumin,  produced  a  proto-albumose,  a  deutero-albumose, 
and  a  toxic  alkaloid,  and  that  these  bodies  were  able  to  account  for  the 
symptoms  occurring  in  this  disease.  The  absolute  proof  of  this  conclusion 
he  furnished  by  the  separation  of  these  substances  from  the  organs  of 
animals  which  had  succumbed  to  the  disease.  The  alkaloid  was  much 
the  most  active  poison,  and  apparently  gave  rise  to  most  of  the  acute 
symptoms  met  with  in  this  disease. 

Etiology. — The  disease  is  acquired  in  man  always  directly  or  in- 
directly from  animals.  The  local  form,  which  occurs  usually  in  butchers, 
is  acquired  directly  by  the  introduction  of  the  bacilli  through  a  wound, 
when  dressing  the  carcase  of  an  animal  affected  with  splenic  fever.  It 
may  be  also  acquired  indirectly  by  wool-sorters,  tanners,  and  those  engaged 
in  occupations  where  they  come  in  contact  with  the  hides  or  hair  of 
animals,  by  the  entrance  of  the  spores  through  a  wound  or  scratch, 
although  this  may  occur  without  visible  injury  to  the  skin.  It  has  been 
suggested  that  the  bites  of  flies  which  have  settled  on  the  carcase  may 
also  convey  the  disease.  The  internal  form  of  anthrax,  where  the  disease 
originates  from  the  intestinal  canal  or  through  the  lungs,  is  due  to  the 
inhalation  or  ingestion  of  spore-bearing  material. 

Morbid  anatomy  and  pathology. — In  malignant  pustule  we 
have  an  inflammatory  exudation  under  the  skin,  rapidly  extending  into- 
the  deeper  layers,  which  is  accompanied  by  haemorrhages,  due  to  the 
rupture  of  the  vessels.  The  cells  at  the  same  time  undergo  a  process  of 
coagulation  necrosis,  and  the  central  portion,  which  acquires  a  black 
colour  from  the  effused  blood,  forms  the  eschar  which  is  so  typical  of  this 
form  of  the  disease. 

In  the  pulmonary  form  the  lungs  are  usually  collapsed,  but  the  most 
characteristic  feature  is  the  presence  of  clear  serous  fluid  in  the  pleural 
and  pericardial  cavities,  although  there  may  be  no  signs  of  inflammation 
of  the  serous  membranes.  There  may  be  small  patches  of  broncho- 
pneumonia scattered  throughout  the  lungs,  and  small  haemorrhages,  but  it  is 
much  more  usual  to  find  the  mucous  membrane  of  the  trachea  and  upper 
bronchi  swollen  irregularly,  and  certain  patches  specially  affected  where 
small  haemorrhages  appear  to  have  occurred.  The  bronchial  and  medi- 
astinal glands  are  very  much  enlarged,  and  filled  with  haemorrhages.     The 


ANTHRAX.  455 

pleural  and  pericardial  effusions  which  are  so  characteristic  of  this  disease 
are  probably  due  to  the  enlarged  glands  pressing  on  the  blood  vessels,  or, 
as  has  been  suggested  by  Greenfield,  to  the  rapid  obstruction  of  the  lymph 
channels  in  the  glands  interfering  with  the  lymph  absorption.  The 
collapse  of  the  lungs,  on  the  other  hand,  may  be  ascribed  to  the  swollen 
condition  of  the  air  passages,  offering  an  obstruction  to  the  entrance  of  air. 

Symptoms. — The  symptoms  and  course  of  the  disease  vary  greatly  in 
different  cases.  The  various  forms  are  usually  described  under  the  region 
of  the  body  primarily  affected :  First,  the  external,  commonly  known  as 
malignant  pustule;  second,  the  internal,  which  includes  the  intestinal, 
and  the  pulmonary.  It  must  be  borne  in  mind,  however,  that  in  either 
of  these  forms  there  may1  be  little  or  no  local  manifestation,  the  disease 
at  once  becoming  general,  and  constituting  what  is  practically  a  septicaemia. 

External. — The  first  sign  of  this  form  of  the  disease,  commonly 
known  as  malignant  pustule,  consists  usually  in  the  appearance  of  a  small  red 
papule,  which  rapidly  extends  in  a  few  hours  into  a  large  red  swelling.  On 
the  summit  of  the  swelling  a  small  raised  papule  then  forms,  which  becomes 
vesiculated,  and  ultimately  forms  a  dry  scab  on  the  surface,  and  round 
this  dark  eschar  there  occurs  frequently  a  circle  of  vesicles,  while  the  swell- 
ing itself  becomes  greatly  indurated,  and  usually  continues  to  spread ;  at 
the  same  time,  the  poison  is  taken  up  by  the  lymphatics,  and  the  glands 
enlarge.  The  formation  of  the  pustule  is  sometimes  wanting,  and  the 
nature  of  the  swelling  at  the  same  time  is  different,  assuming  more  an 
oedematous  character,  while  the  lymphatics  are  not  affected  to  the  same 
extent.  This  form  is  usually  much  more  fatal  than  the  other,  the 
disease  apparently  becoming  much  more  rapidly  generalised  and  invading 
the  whole  system.  The  course  of  the  disease  and  the  nature  of  the 
symptoms  vary  greatly,  being  dependent,  no  doubt,  on  the  quantity  of  the 
infective  agent  primarily  inoculated,  the  virulence  of  the  material,  and  the 
constitutional  peculiarities  of  the  person  affected.  These  factors  determine 
the  time  which  intervenes  before  the  carbuncle  makes  its  appearance,  its 
character,  progress,  and  tendency  to  remain  localised  or  to  invade  the 
system.  Where  the  local  reaction  is  great,  we  should  expect,  from  our 
experimental  knowledge  of  the  disease,  that  the  tissues  of  the  affected  person 
were  exhibiting  a  certain  resistance  to  the  infection — in  fact,  attempting 
to  localise  it ;  while,  on  the  other  hand,  where  little  reaction,  or  only 
oedema  is  to  be  observed,  no  resistance  is  offered  to  the  disease  becoming 
generalised  and  running  a  rapid  course.  It  is  due  to  this  fact — that  the 
disease  is  localised  in  the  earlier  stage — that  the  surgical  treatment  of 
malignant  pustule  is  so  successful ;  as  even  where  the  whole  of  the  infective 
material  may  not  be  removed,  by  reducing  the  amount  of  the  virus  present 
we  tend  to  reduce  the  quantity  coming  into  action  to  that  which  would 
constitute  a  vaccine.  The  carbuncle  gives  rise  to  little  pain,  and  in  the 
early  stage  the  only  constitutional  symptom  is  a  feeling  of  general  malaise ; 
but  as  the  poison  becomes  absorbed  into  the  system  the  temperature  may 
rise  to  102°  F.,  or  even  104°  F. 

Internal. — The  forms  of  internal  anthrax  vary  greatly,  and  this  is  due 
to  the  fact  that  the  disease  may  give  rise  to  little  or  no  local  manifestations 
at  the  point  of  entrance,  similar  to  the  cedematous  variety  of  the  external 
form  of  the  disease;  while,  on  the  other  hand,  it  may  give  rise  to  local 
lesions  in  the  intestines  or  lungs,  corresponding  in  character  to  the  ordi- 
nary malignant  pustule.  The  onset  of  the  disease  is  often  sudden,  but 
sometimes  is  preceded  by  premonitory  symptoms  of  depression,  pains  in 


456  GENERAL  DISEASES. 

the  limbs  and  back,  and  cold  perspirations.  This  is  succeeded  by  extreme 
prostration,  which  rapidly  terminates  in  collapse.  The  temperature  varies 
greatly,  and  may  be  very  high  or  only  slightly  above  the  normal. 

Intestinal. — In  this  form  we  may  have,  in  addition  to  the  general 
symptoms,  others  indicating  the  special  system  affected :  thus  pain  in  the 
abdomen,  vomiting,  diarrhoea,  with  or  without  bloody  stools,  and  bleeding 
from  the  pharynx,  may  sometimes  be  noted.  The  glands  in  the  neck  are 
also  sometimes  enlarged. 

Pulmonary. — In  this  form,  commonly  known  as  woolsorter's  disease, 
the  symptoms  of  acute  bronchitis  or  pneumonia  may  be  more  or  less 
present,  but  the  local  signs  of  the  disease  are  out  of  all  proportion  to  the 
constitutional  symptoms  and  effects. 

Diagnosis. — In  the  early  stage,  the  external  form  can  only  be  recog- 
nised from  the  history  of  the  case  indicating  exposure  to  the  contagion. 
In  the  later  stage,  the  malignant  pustule  is  very  characteristic,  and,  in  case 
of  doubt,  could  be  recognised  bacteriologically,  or  by  the  inoculation  of 
mice  or  guinea-pigs.  In  the  oedematous  form  the  signs  and  symptoms  are 
of  little  assistance,  and  we  should  have  to  rely  upon  the  bacteriological 
diagnosis  to  come  to  a  definite  decision.  In  the  internal  form  of  anthrax 
the  diagnosis  must  always  be  attended  with  the  greatest  difficulty,  and  we 
must  rely  chiefly  on  the  possibility  of  the  patient  having  been  exposed  to 
the  infection. 

Prognosis. — In  the  case  of  external  anthrax,  where  the  patient  is 
brought  under  early  treatment,  the  majority  of  the  cases  recover.  The 
oedematous  form  is,  however,  usually  rapidly  fatal.  In  all  cases  of  internal 
anthrax,  on  the  other  hand,  the  prognosis  must  be  exceedingly  unfavourable. 

Treatment. — External  anthrax  should  be  at  once  treated  surgically 
by  excision,  if  possible,  and  cauterisation  with  pure  carbolic  acid.  Where 
the  carbuncle  is  very  large,  crucial  incisions  should  be  made,  and  the 
wound  again  cauterised  with  strong  carbolic  acid.  In  these  cases  5  per 
cent,  carbolic  acid  has  been  injected  into  the  surrounding  tissues  appar- 
ently with  advantage.  It  is  hardly  necessary  to  say  that  all  discharges 
should  be  most  carefully  disinfected.  In  internal  anthrax  no  special 
treatment  at  present  known  appears  to  exert  a  beneficial  influence. 

G.  E.  CARTWRIGHT  WOOD. 


GLANDERS. 

A  contagious  febrile  disease,  communicated  to  man  from  the  horse,  ass, 
or  mule,  due  to  the  multiplication  in  the  system  of  the  glanders  bacillus 
(Bacillus  mallei),  and  characterised  by  specific  inflammatory  lesions  of  the 
nasal  and  respiratory  mucous  membranes,  the  lymphatic  vessels,  and  glands. 
History. — This  disease  has  long  been  recognised  as  a  common  and 
very  deadly  affection  for  horses,  and  up  to  quite  recent  times  was  described 
as  two  distinct  affections,  according  to  the  nature  of  the  characteristic 
lesions.  In  those  cases  where  the  nasal  and  respiratory  mucous  membranes 
are  most  obviously  affected,  the  disease  was  termed  glanders ;  while  in  those 
cases  in  which  the  lymphatic  system  was  chiefly  affected  the  disease  was 
termed  farcy.  The  two  sets  of  lesions  are,  however,  usually  associated,  or 
occur  in  different  stages  of   the  disease,  and  no  reason  now  exists  for 


GLANDERS.  457 

regarding  them  as  distinct,  since  they  are  both  due  to  the  presence  of  the 
same  organism.  It  has,  in  addition,  been  proved  that  the  same  virus  may 
give  rise  to  the  two  sets  of  lesions,  when  inoculated  into  different  horses. 
As  early  as  1869,  Chauveau  suggested  that  the  virus  must  be  particulate 
in  its  nature  ;  but  it  was  only  in  1882  that  Loffler  and  Schutz  described  a 
definite  organism — the  glanders  bacillus — as  occurring  in  the  infected 
tissue.  This  organism  they  were  able  to  cultivate,  on  artificial  media, 
outside  the  animal  body,  as  a  pure  culture  with  which  they  could  reproduce 
the  disease  in  other  animals. 

Etiology. — Glanders,  when  occurring  in  man,  is  due  to  inoculation 
with  the  virus  of  the  disease,  usually  directly  from  a  horse,  but  sometimes 
from  man,  and  even  from  artificial  cultures  used  in  laboratory  experiments. 
It  is  met  with  most  frequently  among  those  employed  in  the  care  of  horses, 
and  its  mode  of  communication  can  in  most  cases  be  easily  traced.  The 
virus  usually  finds  an  entrance  through  some  breach  in  continuity  of  the 
skin  or  mucous  membrane,  which  has  come  in  contact  with  discharges  from 
the  diseased  surface.  It  is,  however,  possible  that  infection  may  occur 
through  the  healthy  mucous  membrane.  The  glanders  bacilli  are  small 
slender  rods  with  rounded  ends,  somewhat  shorter  and  thicker  than  the 
tubercle  bacillus.  They  occur  either  singly  or  in  pairs,  biit  never  in  long 
threads,  and  are  non-motile.  The  bacilli  are  not  so  readily  demonstrated 
as  in  many  other  diseases,  owing  apparently  to  the  fact  that  they  absorb 
the  stain  readily,  but  give  it  up  as  readily  during  the  process  of  decolorisa- 
tion.  They  can  be  stained  in  aniline  gentian-violet  or  carbol-fuchsin,  and 
then  slowly  decolorised  in  a  1  per  cent,  solution  of  acetic  acid  and  water, 
to  which  a  small  quantity  of  tropseoline  has  been  added.  The  bacillus  will 
not  grow  at  a  temperature  under  25°  C,  or  over  42°  C.  When  inoculated 
on  glycerin  agar,  and  incubated  at  37°  C,  in  three  or  four  days  a  clearly- 
defined  whitish,  moist,  shiny  coat  forms  along  the  tract  of  the  inoculation. 
The  organism  grows  well  on  potato  as  a  thin  amber-yellow  transparent 
film,  which  ultimately  takes  on  a  reddish  brown  colour.  This  appearance  is 
very  characteristic,  and  serves  to  distinguish  it  from  most  other  organisms. 
Among  the  smaller  animals,  field-mice,  guinea-pigs,  and  cats  are  most  easily 
affected,  and  may  be  used  for  purposes  of  diagnosis.  The  ordinary  anti- 
septics, such  as  carbolic  acid  and  Condy's  fluid,  in  the  usual  dilutions, 
rapidly  destroy  the  virus.  It  is  rather  surprising  that,  although  this 
organism  does  not  form  resistant  spores,  still,  when  maintained  in  a  dry 
state,  it  may  retain  its  activity  for  almost  three  months. 

Morbid  anatomy  and  pathology. — This  disease  is  characterised 
by  the  formation  of  swellings  and  nodules  in  the  skin,  mucous  membranes, 
lymphatics,  and  internal  organs.  These  nodules  consist  of  a  deposit  of 
granulation  tissue,  which  in  the  acute  form  passes  on  into  pus  formation, 
and  frequently  present  the  appearance  of  a  pyaemia  ;  while  in  the  chronic 
form  they  develop  more  in  the  direction  of  caseation.  The  deposits  tend 
to  break  down,  so  that  ulcers  form,  which  present  a  great  tendency  to 
spread.  These  ulcers  occur  frequently  on  the  nasal  and  respiratory  mucous 
membranes,  but  also  on  the  skin.  The  characteristic  bacilli  are  to  be  found 
in  the  nodules,  and  can  be  recognised  by  appropriate  staining. 

Symptoms. — The  period  of  incubation  varies  greatly,  from  a  few 
days  to  several  weeks,  and  it  may  be  stated  generally  that  the  severity  of 
the  case  varies  inversely  with  the  length  of  this  period.  This  variation 
is  no  doubt  due  to  the  quantity  of  the  virus  primarily  introduced  and  its 
"virulence,  on  the  one  ha.nd ;  while  the  nature  and  the  condition  of  the 


458  GENERAL  DISEASES. 

tissue  inoculated,  as  well  as  the  natural  susceptibility  or  insusceptibility  of 
the  person  affected,  on  the  other  hand,  may  exert  an  important  role.  We 
have  the  two  types  of  the  disease,  described  as  glanders  and  farcy  ;  but,  in 
addition,  each  of  these  is  subdivided  into  an  acute  and  a  chronic  form. 
The  first  signs  of  the  disease  are  usually  general  febrile  disturbance  ;  whilst 
the  wound,  if  present,  shows  redness,  swelling,  and  lymphangitis.  The 
mucous  membrane  of  the  nose  may  then  become  involved,  and  the  nodules 
which  are  formed  may  break  down,  forming  ulcers  which  give  rise  to  a 
muco-purulent  discharge.  An  eruption  of  papules  may  now  appear  on  the 
face  and  on  other  parts  of  the  body,  and  these  may  form  vesicles,  and 
finally  pustules.  This  disease  may  run  a  very  rapid  course,  or  may  extend 
over  months.  In  the  other  type  of  the  disease  the  lymphatics  are  chiefly 
affected,  and  at  intervals  along  their  course  they  may  become  enlarged  and 
filled  with  purulent  material,  forming  what  are  called  farcy  buds.  In  the 
later  stages  it  may  exhibit  the  nasal  and  other  lesions  ;  so  that,  as  already 
stated,  no  sharp  line  can  be  drawn  between  the  two  types. 

Diagnosis. — In  the  early  stage  the  disease  is  to  be  recognised  by  the 
history  alone,  as  the  symptoms  at  that  period  might  be  ascribed  to  various 
fevers,  and  even  pyasmia.  The  fact  that  those  affected  are  almost  invariably 
employed  among  horses,  and  are  therefore  liable  from  time  to  time  to  come 
into  contact  with  diseased  animals,  or  the  morbid  discharges  from  them, 
greatly  assists  in  coming  to  a  decision,  as  one  can,  as  a  rule,  easily  trace 
the  mode  of  communication.  Where  a  womid  exists,  the  origin  of  the 
disease  is,  of  course,  obvious. 

In  the  case  of  animals,  where  the  disease  frqeuently  runs  a  very  chronic 
course,  so  that  the  diagnosis  from  the  signs  and  symptoms  may  be  quite 
impossible,  an  absolutely  decisive  opinion  may  be  formed  by  the  injection 
of  mallein.  This  consists  of  a  glycerin  extract  of  the  culture  of  the  glanders 
bacillus,  which  gives  rise,  on  injection  into  an  infected  animal,  to  a  marked 
rise  of  temperature  and  a  distinct  local  swelling. 

In  the  more  chronic  cases,  it  has  been  suggested  that  the  disease  may 
be  confounded  with  tubercle  and  syphilis ;  but  if  any  such  doubt  should 
exist,  a  bacteriological  examination  of  the  material,  controlled,  if  necessary  r 
by  inoculation  of  animals,  should  at  once  settle  the  question. 

Prognosis. — The  prognosis  in  glanders  is  always  unfavourable,  in 
the  acute  form  only  1  or  2  per  cent,  of  those  affected  recovering;  but, 
on  the  other  hand,  in  the  more  chronic  form,  as  many  as  50  per  cent,  may 
recover.  The  longer  the  period  of  incubation,  and  the  more  slowly  the 
symptoms  develop,  and  the  less  pronounced  the  constitutional  disturbance, 
the  more  hopeful  is  the  prognosis. 

Treatment. — Local. — Any  bite  or  open  wound  which  may  have  come 
in  contact  with  suspected  glanders  material,  should  be  disinfected  and 
cauterised  at  once  with  strong  carbolic  acid,  and  if  seen  at  a  later  stage, 
may  even  then  be  excised  with  advantage.  The  abscesses  and  collections 
of  glanders  material  should  be  opened  and  evacuated  on  the  ordinary 
surgical  principles,  and  great  care  should  be  exercised  as  regards  the 
disinfection  of  all  the  discharges. 

Constitutional. — Our  aim  must  be  to  support  the  strength  of  the  patient, 
and  generally  to  avoid  the  tendency  towards  death. 

G.  E.  CAKTWKIGHT  WOOD. 


SNAKE-BITE.  459 


SNAKE-BITE. 


Disease  resulting  from  the  introduction  into  the  system  of  a  poisonous 
secretion  produced  by  certain  members  of  the  Ophidia,  known  as  snake 
venom,  which  gives  rise  to  acute  local  and  constitutional  symptoms. 

In  the  British  Isles  the  only  venomous  snake  is  the  common  viper 
(Pclias  bcrus) ;  in  India,  the  cobra  (Naia  tripudians) ;  in  Australia,  the 
brown  snake  (Diemcnia  superciliosa),  the  tiger  snake  (Hoplocephalus  curtus), 
the  black  snake  (Pseudechis  porphyriacus),  and  the  death  adder  (Acantophis 
antarctica) ;  and  in  America,  the  rattle-snakes  (Crotalus  adalanteus),  and 
the  moccasin  (Ancistrodon  piscirorus)  are  the  most  common. 

Etiology  and  Pathology. — The  older  accounts  given  by  different 
observers  of  the  action  of  snake  venom  on  animals  have  been  so  contra- 
dictory, that  no  definite  conclusions  could  be  drawn  from  their  results ;  but 
quite  recently  C.  J.  Martin  has  been  able  to  explain  these  by  taking  into 
consideration  the  amount  of  the  poison  and  its  method  of  introduction. 
The  active  ingredients  of  venom  appear  to  consist  of  a  proteid  body, 
coagulated  and  rendered  practically  inert  on  heating  to  85°  C,  and  a  non- 
coagulable  diffusible  proteid  which  is  unaffected  by  subjection  to  this 
temperature.  He  has  been  able  to  accomplish  the  separation  of  these  two 
bodies  by  filtration  through  a  film  of  gelatin  or  silicic  acid,  occupying  the 
pores  of  the  porcelain  of  a  Pasteur-Chamberland  filter.  The  diffusible 
uncoagulable  proteid,  which  is  an  albumose,  passes  through  unchanged 
into  the  filtrate,  while  the  coagulable  ingredient  of  the  venom  is  retained 
on  the  surface  of  the  filter.  The  coagulable  proteid  poison  acts  directly  on 
the  blood  corpuscles,  inducing  their  disintegration,  giving  rise  to  intra- 
vascular clotting,  which  is  a  frequent  cause  of  death  in  animals  when  the 
venom  is  injected  intravenously.  It  also  acts  as  a  direct  poison  to  the 
cardiac  muscle.  When  injected  subcutaneously,  it  acts  directly  on  the 
lining  wall  of  the  blood  vessels  and  of  the  blood  corpuscles,  giving  rise  to 
effusion  and  haemorrhages.  This  poison  accordingly  acts  directly  on  the 
tissues,  giving  rise  to  the  local  symptoms  and  to  the  haemorrhages  from 
the  blood  vessels  which  are  so  frequently  observed.  The  uncoagulable 
proteid  or  albumose,  on  the  other  hand,  affects  chiefly  the  nervous  system, 
paralysing  especially  the  respiratory  centre  in  the  medulla  oblongata,  and 
also  the  nerve  terminations  in  muscles. 

The  difference  in  the  results  observed  by  the  introduction  of  the 
venom  subcutaneously  or  intravenously  is  due  to  the  much  slower 
absorption  in  the  first  case,  of  the  poison,  especially  the  non-coagulable 
proteid,  into  the  circulation.  When  introduced  directly  into  the  blood, 
the  experiment  is  usually  brought  to  a  termination  by  the  occurrence  of 
intravascular  clotting,  which  masks  and  prevents  the  development  of  the 
symptoms  produced  by  the  action  of  the  albumose  poison.  The  propor- 
tion of  coagulable  to  non-coagulable  poison  present  in  different  venoms 
varies  enormously,  that  of  the  rattle-snake  {Crotalus)  containing  as  much 
as  25  per  cent.,  whilst  that  of  the  cobra  contains  only  1'75  per  cent. 
(Weir  Mitchell  and  Beichert).  This  fact  accounts  for  the  variation  in  the 
local  and  constitutional  effects  produced  by  the  bites  of  different  species 
of  snakes. 

Calmette  states  that  the  physiological  action  of  the  venoms  of  different 
species  of  snakes  is  in  essence  alike.  The  only  difference  consists  in  the 
local  action  of  the  venoms,  and  the  poison  which  produces  this  effect  can 


460  GENERAL  DISEASES. 

be  separated  from  those  which  produce  the  general  constitutional  effects 
due  to  bulbar  intoxication.  This  is  effected  by  heating  the  venom  at  85°  C. 
for  fifteen  minutes,  when  the  venoms  of  different  species  (colubrine  or 
viperine)  produce  similar  symptoms,  differing  only  in  the  inequality  of 
their  activity.  Phisalix  and  Bertrand,  and  later  Calmette  and  Eraser,  have 
been  able,  by  accustoming  animals  to  gradually  increasing  doses  of  the 
venom,  to  produce  an  antitoxic  serum  which  is  usually  termed  antivenin. 
Calmette  states  that  his  serum  produced  from  the  cobra  de  capello  is  active 
against  the  venoms  of  all  other  serpents,  and  even  of  scorpions,  so  that 
one  serum  can  be  used  in  all  cases  of  snake-bites. 

Symptoms. — The  local  symptoms  consist  chiefly  of  pain,  swelling, 
ecchymoses,  and  partial  paralysis.  If  the  patient  should  recover  from  the 
immediate  effects,  cellulitis  and  sloughing  may  ensue  from  the  organisms 
which  have  found  an  entrance  into  the  weakened  tissues  with  the  venom. 
The  constitutional  symptoms  consist  of  general  depression,  nausea,  fainting, 
accompanied  by  hurried  respiration,  loss  of  consciousness,  and  coma. 

Treatment. — The  immediate  treatment  should  consist  in  the  appli- 
cation of  a  tight  ligature  between  the  site  of  the  bite  and  the  heart, 
which  may  be  followed  by  incision  or  destruction  of  the  bitten  part.  A 
5  or  10  per  cent,  solution  of  permanganate  of  potash,  or,  as  recommended 
by  Calmette,  a  2  per  cent,  solution  of  hypochlorite  of  lime,  which  he  states 
destroy  the  activity  of  the  venom,  may  be  injected  locally  before  the 
ligature  is  removed. 

The  only  constitutional  treatment  from  which  at  present  any  success 
can  be  expected,  is  that  of  attempting  to  antagonise  the  action  of  the  poison 
by  the  injection  of  venom  antitoxine,  a  method  which  is  still  on  its  trial. 
The  strength  of  the  patient  must  of  course  be  supported  by  stimulants, 
such  as  alcohol  and  ammonia,  and  artificial  respiration  may  be  resorted 
to  for  the  purpose  of  assisting  the  patient  over  the  period  of  acute 
intoxication. 

G.  E.  CAKTWRIGHT  WOOD. 


GOUT. 

Gout  is  the  manifestation  of  a  number  of  morbid  tendencies,  some  of 
which  may  be  inherited  and  some  acquired,  which  result  in  the  different 
diseases  associated  with  the  arthritic  diathesis.  If  the  joints  become 
affected,  articular  or  regular  gout  results  ;  if  other  organs  or  tissues  become 
affected,  then  the  term  irregular  gout  is  applied. 

Etiology. — Gout  is  mainly  a  disease  of  middle  and  late  life,  but  it 
may  become  manifest  earlier  if  there  is  a  marked  hereditary  tendency.  It 
most  commonly  occurs  among  males,  due,  no  doubt,  to  the  habits  of  men 
being  more  conducive  to  its  development  than  the  more  temperate  habits 
of  life  of  most  women. 

Hereditary  predisposition  is  the  most  important  factor  in  the  deter- 
mination of  gout.  The  females  of  gouty  families  frequently  escape  the 
apparent  development  of  gout  in  themselves,  yet  transmit  the  liability 
to  the  disease  to  their  children.  It  is  doubtful,  however,  whether  true 
atavism  occurs  in  connection  with  gout,  that  is,  whether  gout  entirely 
misses  a  generation.     It  is  more  probable  that  it  appears  in  some  form, 


GOUT.  461 

irregular  or  otherwise,  in  the  generation  that  it  is  supposed  to  have  passed 
over.  Excessive  indulgence  in  alcohol,  especially  in  the  form  of  wines  and 
beers,  and  excessive  consumption  of  nitrogenous  and  rich  foods,  are  power- 
ful factors  in  the  development  of  gout.  Indolent  habits  and  inadequate 
physical  exercise  also  strongly  predispose  to  gout.  Chronic  lead  poisoning 
predisposes  to  gout,  probably  by  affecting  the  kidneys,  and  so  interfering 
with  the  proper  elimination  of  uric  acid. 

An  attack  of  acute  gout  is  frequently  induced  by  unusual  indulgence 
in  food  or  drink,  or  by  some  powerful  emotion,  such  as  a  fit  of  anger, 
worry,  or  anxiety,  or  by  exposure  to  cold,  or  by  the  receipt  of  some  injury.  ' 
For  the  production  of  gout,  whether  of  the  regular  (articular)  or  irregular 
(abarticular)  type,  the  deposition  of  sodium  biurate  in  the  organ  or  tissue 
affected  is  essential.  The  mere  presence  of  uric  acid  in  the  blood,  in  the 
form  of  dissolved  sodium  quadriurate  or  biurate,  is  insufficient  for  the 
production  of  any  form  of  gout,  in  the  absence  of  deposition  of  the  biurate 
from  the  fluids  of  the  body. 

Pathology. — Gout  is  associated  with  the  presence  in  the  blood  of  an 
excess  of  uric  acid  in  combination  with  sodium.  Uric  acid — H2(C5H2N403) 
— is  bibasic,  and  forms  the  following  three  classes  of  salts: — (1)  the 
neutral  urates,  such  as  Na2(C5H2N403),  the  neutral  sodium  urate ;  (2) 
the  biurates,  such  as  NaH(C5H2N"403),  the  sodium  biurate ;  and  (3)  the 
quadriurates,  such  as  NaH(C5H2N403),  H2(C5H2N403),  the  sodium  quadri- 
urate. Of  these  three  classes  of  salts  the  neutral  urates  cannot  exist 
in  the  living  organism,  and  therefore  take  no  part  in  the  pathology  of  gout. 
It  should  also  be  borne  in  mind  that  uric  acid  does  not  exist  in  the  blood 
in  the  free  state.  Sodium  quadriurate  is  the  soluble  uric  acid  compound 
which  is  originally  present  in  the  blood  of  gouty  subjects.  This  salt  is, 
however,  an  unstable  body,  and  after  a  certain  time  it  unites  with  some  of 
the  sodium  carbonate  of  the  blood  to  form  the  stable  but  much  less  soluble 
sodium  biurate.  If  this  biurate  is  produced  in  larger  quantities  than  the 
fluids  of  the  body  can  retain  in  solution,  it  becomes  precipitated  in  various 
structures  in  the  crystalline  form,  and  then  constitutes  the  gouty  deposit. 

Theories  of  gout. — Different  views  have  been  held  at  various  times 
as  to  the  causation  of  gout.  That  which  regards  gout  as  the  result  of  a 
true  toxic  action,  exerted  by  the  uric  acid  salt  dissolved  in  the  blood,  is 
untenable  for  these  reasons : — (1)  There  is  no  experimental  proof  that  uric 
acid  is  a  poison  ;  (2)  a  gouty  subject,  just  prior  to  the  advent  of  an  attack 
of  acute  gout,  shows  no  signs  of  poisoning,  although  the  fluids  of  his  body 
are  then  saturated  with  a  salt  of  uric  acid;  and  (3)  in  certain  blood 
disorders,  such  as  severe  ansemia  and  leucocythsemia,  the  blood  is  frequently 
highly  charged  with  a  salt  of  uric  acid  without  the  production  of  any  toxic 
symptoms  that  could  be  referred  to  that  substance.  Again,  the  various 
suggestions  as  to  the  uric  acid  being  merely  a  bye-product  in  the  gouty 
process  quite  fail  to  explain  many  of  the  phenomena  of  gout.  The  remain- 
ing view,  that  the  uric  acid  salt  only  exerts  a  baneful  effect  after  precipita- 
tion from  the  blood  and  deposition  in  the  tissues,  appears  to  be  the  most 
tenable  one.  This  theory  regards  the  soluble  uric  acid  salt  as  being 
destitute  of  poisonous  qualities,  and  as  producing  no  harmful  results  so 
long  as  it  remains  dissolved  in  the  fluids  of  the  body.  When,  however, 
the  fluids  become  over-saturated  with  this  compound,  a  crystalline  deposi- 
tion of  sodium  biurate  occurs,  which  then  acts  as  a  mechanical  irritant  to 
the  tissues  and  structures  in  which  the  deposition  takes  place. 

The  source  of  uric  acid. — The  over-charging  of  the  blood  in  gout  with 


462  GENERAL  DISEASES. 

a  salt  of  uric  acid  must  be  due  to  one  or  more  of  the  following  causes : — 
(1)  Production  of  uric  acid  in  the  normal  manner,  but  insufficient  excretion 
of  it ;  (2)  over-production  of  uric'  acid  while  the  excretion  remains  about 
normal ;  and  (3)  diminished  destruction  of  uric  acid  by  imperfect  oxida- 
tion or  by  some  other  means.  The  two  last-mentioned  views  are 
untenable ;  for  with  regard  to  the  last  there  is  no  proof  that  the  process 
of  oxidation,  or  any  other  process  going  on  within  the  organism,  destroys 
uric  acid,  and  the  second  is  based  on  the  erroneous  assumption  that  the 
kidneys  can  only  eliminate  a  certain  amount  of  uric  acid,  whereas  there  is 
abundant  proof  that  an  increased  production  of  uric  acid  does  not  lead 
to  gout  so  long  as  the  kidneys  remain  in  a  normal  condition.  We  are 
therefore  restricted  to  the  explanation  of  the  cause  of  the  presence  of 
the  salt  of  uric  acid  in  the  blood  in  gout  being  due  to  the  production 
of  uric  acid  at  the  normal  seat  or  seats  of  its  manufacture,  and  to  its 
subsequent  imperfect  excretion.  That  a  deficient  excretion  of  uric  acid 
occurs  in  gout,  has  been  shown  by  recent  accurate  estimations  of  the 
elimination  of  uric  acid  in  gouty  subjects. 

The  question  next  arises,  whether  the  uric  acid,  which  in  gout  is 
imperfectly  excreted,  is  manufactured  in  the  organs  and  tissues  of  the 
body  generally,  and  thence  passed  into  the  general  circulation ;  or  whether 
it  is  produced  only  in  the  kidneys,  and  then,  in  consequence  of  imperfect 
excretion  by  these  organs,  the  residual  quantity  of  uric  acid  is  absorbed 
from  them  into  the  general  circulation.  Now,  if  uric  acid  be  produced 
as  such  in  the  liver,  or  spleen,  or  tissues  generally,  then  it  follows  that 
it  must  be  conveyed  in  the  blood  to  the  kidneys  in  order  to  be  excreted ; 
and  if  this  be  the  case,  it  ought  to  be  capable  of  detection  in  the  blood 
of  healthy  individuals,  and  of  healthy  animals,  that  excrete  uric  acid. 
Careful  examinations  of  the  blood  of  healthy  human  beings  and  of  various 
animals  has,  however,  always  failed  to  reveal  the  presence  of  uric  acid, 
though  urea  is  always  present  in  such  blood.  This  evidence  suggests  that 
since  uric  acid  is  not  conveyed  in  the  blood  to  the  kidneys,  it  must  be 
manufactured  in  those  organs,  and  this  view  of  the  renal  formation  of 
uric  acid  is  supported  by  the  fact  that,  although  birds  excrete  the  whole 
of  their  urinary  nitrogen  in  the  form  of  uric  acid,  and  not  at  all  in  the 
iorm  of  urea,  yet  the  blood  of  birds  always  contains  an  abundance  of  urea, 
and  only  very  minute  amounts  of,  or  no,  uric  acid.  This  evidence  that  the 
blood  of  birds  always  contains  urea,  but  little  or  no  uric  acid,  whilst  the 
urinary  excrement  of  birds  contains  no  urea,  but  consists  entirely  of 
compounds  of  uric  acid,  can  only  be  explained  by  the  view  that  the  uric 
acid  is  manufactured,  at  all  events  to  some  extent,  in  the  kidneys,  and  that 
the  urea  brought  to  the  kidneys  by  the  blood  is  the  antecedent,  or  one 
of  the  antecedents,  out  of  which  the  kidneys  manufacture  that  uric 
acid. 

The  renal  origin  of  gout. — It  would  therefore  appear  that  the  first 
step  in  the  pathogenesis  of  gout  is  a  failure  on  the  part  of  the  kidneys 
— from  transient  or  organic  mischief — to  perfectly  excrete  the  uric  acid 
formed  in  them,  and  that  consequently  absorption  of  the  non-excreted 
portion  takes  place  from  them  into  the  general  circulation,  where  it  exists 
at  first  as  sodium  quadriurate,  and  so  forms  the  source  from  which  the 
gouty  deposit  is  derived.  It  is  probable  that  some  affection  of  the  kidneys 
always  precedes  any  gouty  manifestations,  and  that  this  possibly  transient 
affection  may  subside  if  the  exciting  cause  of  it  be  removed,  or  it  may 
p>ass   on   to   an   obvious   structural  lesion.     It   may   be   that  this  renal 


GOUT.  463 

vulnerability  constitutes  the  hereditary  factor  of  gout.  The  affection  may 
also  be  started  by  various  causes,  such  as  excessive  indulgence  in  nitro- 
genous foods,  wines,  and  beers,  the  toxic  effect  of  lead,  and  the  influence 
of  nervous  impulses,  such  as  mental  shocks,  severe  accidents,  etc.  The 
anatomical  seat  of  the  kidney  affection  is  apparently  in  the  epithelium  of 
the  convoluted  tubes,  whilst  the  increase  of  interstitial  tissue  is  most 
likely  a  secondary  change. 

Uric  acid  is  probably  formed  in  the  kidneys  by  the  combination  of  urea 
with  glycocine  or  with  one  of  the  derivatives  of  the  latter  body.  This 
view  is  supported  by  the  fact  that  uric  acid  can  be  made  artificially  by 
the  union  of  urea  with  glycocine,  and  also  by  the  well-known  fact  that 
amongst  the  carnivora,  whose  urine  contains  little  or  no  uric  acid,  the  bile 
contains  no  glycocholic  but  only  taurocholic  acid,  and  therefore  yields  no 
glycocine. 

Formation  and  seats  of  gouty  deposits. — As  previously  mentioned, 
the  unstable  sodium  quadriurate  circulating  in  the  blood  of  gouty  subjects 
becomes  converted  after  a  variable  period  of  time  into  the  much  less 
soluble  sodium  biurate,  which  then  deposits  in  those  tissues  which,  either 
on  account  of  having  received  previous  slight  injuries,  or  because  of  their 
poor  vascular  supply,  and  the  sluggish  movement  of  fluids  in  them, 
specially  favour  its  deposition.  Such  tissues  are  structures  belonging 
to  the  connective  tissue  class — cartilages,  ligaments,  tendons,  and  the 
eutaneous  and  subcutaneous  connective  tissues.  It  is  quite  possible  that 
nervous  influence  may  accelerate  this  deposition  of  biurate.  It  is  well 
known  that  whatever  depresses  the  nervous  system — such  as  great  fatigue, 
rage,  fright,  worry,  or  excitement — may  cause  an  attack  of  gout  in  a  gouty 
subject.  This  is  probably  due  to  nervous  influences  depressing  the 
excretory  power  of  the  kidneys  for  uric  acid,  and  so  leading  to  an  increased 
absorption  of  quadriurate  into  the  general  circulation.  The  great  toe  joints 
and  the  ears  are  the  commonest  seats  of  the  gouty  deposit.  The  reasons 
for  the  selection  of  the  toe  joints  are,  the  liability  of  the  joint  to  injury, 
from  having  to  support  the  weight  of  the  body,  and  from  being  subjected  to 
sudden  shocks,  the  remoteness  of  the  joint  from  the  heart,  so  that  the 
force  of  the  circulation  is  at  its  minimum  at  that  part,  and  the  poor 
vascularity  of  the  tissues  of  the  joint.  In  the  helix  of  the  ear  the 
sluggish  circulation  and  the  coldness  of  the  organ  may  account  for  the 
frequency  with  which  uratic  deposits  are  found  in  that  part. 

Cause  of  the  inflammation  accompanying  the  gouty  paroxysm. — 
The  gouty  paroxysm  is  due  to  precipitation,  in  the  crystalline  form,  of 
sodimn  biurate,  the  crystals  being  distributed  throughout  the  implicated 
tissue  in  the  form  of  delicate  needles,  aggregated  into  tufts,  bundles,  and 
stars.  When  deposition  occurs  in  cartilage,  the  crystalline  deposit  acts  as 
an  irritant,  and  causes  inflammation  leading  to  proliferation  and  necrosis 
of  cartilage  cells,  which  may  be  followed  by  erosion  of  cartilage  and 
of  uratic  deposits,  and  consequent  displacement  of  the  latter  into  the 
cavity  of  the  joint.  Although  the  inflammatory  part  of  an  acute  gouty 
attack  is  secondary  to  the  deposition  of  sodium  biurate  crystals,  it  seems 
to  be  necessary  that  such  deposition  should  occur  fairly  copiously  and 
suddenly,  in  order  to  start  the  inflammatory  process.  Undoubtedly,  as  in 
cases  of  chronic  gout,  the  biurate  may  deposit  slowly  and  quietly  in  joints, 
without  the  development  of  any  acute  attack. 

Symptoms. — Acute  gout. — Twinges  of  pain  m  some  of  the  joints 
may  occasionally  precede  the  acute  attack,  but,  as  a  rule,  no  warning 


464  GENERAL  DISEASES. 

ushers  in  the  first  attack  of  gout.  Subsequent  attacks  may  be  preceded 
by  dyspepsia,  constipation,  mental  depression,  or  loss  of  appetite.  The 
seizure  most  frequently  occurs  in  the  early  hours  of  the  morning,  when 
the  patient  is  awakened  by  severe  pain,  generally  in  the  great  toe.  The 
pain  increases  in  intensity,  but  after  some  hours  partial  abatement, 
accompanied  by  a  gentle  perspiration,  occurs.  In  the  morning  the  toe  is 
swollen,  the  skin  is  tense,  shiny,  of  a  purplish  red  colour,  and  extremely 
tender,  and  the  veins  are  distended.  During  the  second  night  the  severity 
of  the  pain  may  recur,  and  such  recurrence  may,  in  the  absence  of  suitable 
treatment,  take  place  for  many  days.  The  pain  in  the  joint  is  excruciat- 
ing, and  is  quite  out  of  proportion  to  the  external  signs  of  inflammation. 
As  the  attack  subsides  the  swelling  and  redness  of  the  affected  part  lessen,, 
the  skin  itches  and  pits  on  pressure,  and  desquamation  follows.  The 
oedema  around  the  joint  is  characteristic,  and  is  useful  in  distinguishing 
the  affection  from  rheumatism.  Gouty  inflammation  of  a  joint  is  not 
followed  by  suppuration.  The  temperature  most  commonly  ranges  from 
99°  to  102°  F.,  and  the  attack  is  generally  accompanied  by  thirst,  anorexia,, 
and  constipation,  whilst  the  urine  is  scanty,  high  coloured,  and  usually 
deposits  amorphous  urates  on  cooling.  Temporary  albuminuria  has  been 
frequently  observed  during  the  early  stages  of  a  paroxysm,  and  occasionally 
slight  albuminuria  lasts  throughout  the  attack.  An  attack  of  acute  gout 
lasts  on  an  average  from  eight  to  fourteen  days  in  persons  of  strong 
constitution,  but  with  advancing  age  the  duration  becomes  prolonged. 
After  an  attack  of  acute  gout  a  patient  frequently  feels  much  better  in 
health  than  before  the  attack.  A  first  attack  of  gout  may  not  be  followed 
by  another,  provided  attention  be  paid  to  diet  and  the  general  mode  of  life. 
On  the  other  hand,  frequent  recurrences  may  occur.  The  majority  of  first 
attacks  of  gout  occur  in  the  great  toe  joint,  but  the  disease  may  start  in 
the  ankles,  instep,  knee,  small  hand  joints,  elbows,  and  very  occasionally  in 
the  shoulders  and  hips.  The  selection  of  any  particular  joint  for  a  primary 
attack  is  probably  dependent  on  slight  inflammatory  or  trophic  changes  in 
that  joint,  from  some  recent  injury  or  strain. 

Chronic  gout. — As  the  recurrence  of  gout  becomes  more  frequent, 
more  joints  are  affected,  and  the  attacks  also  become  more  prolonged, 
unless  efficacious  treatment  is  resorted  to.  Tophi  are  apt  to  form  in 
various  localities,  and  to  give  rise  to  the  so-called  tophaceous  gout.  These 
tophi  consist  mainly  of  deposits  of  sodium  biurate  under  the  skin,  and  are 
principally  found  in  the  auricles  of  the  ears,  in  the  vicinity  of  joints, 
and  in  the  bursee  over  joints.  If  excessive  accumulation  of  the  biurate 
occurs,  these  tophi  assume  a  great  size,  and  may  then  cause  the  integument 
to  give  way,  when  a  discharge  of  a  thick  creamy  fluid,  containing  an 
abundance  of  crystals  of  sodium  biurate,  takes  place.  The  swelling  in  the 
vicinity  of  a  joint  may  give  rise  to  fluctuation,  but  such  swelling  should 
never  be  opened.  Considerable  enlargement  and  deformity  of  joints  may 
occur  in  connection  with  chronic  gout,  to  which  the  deposits  of  sodium, 
biurate  only  contribute  in  small  part.  .  In  such  cases  the  enlargement  is 
due  to  thickening  of  the  synovial  membrane,  and  to  overgrowth  of  the  car- 
tilages and  of  the  ends  of  the  bones  and  surrounding  fibrous  tissue.  This 
form  constitutes  the  so-called  chronic  deforming  gout.  Permanent  de- 
formity of  the  affected  joints  may  result,  and  partial  dislocations  and 
ankyloses  may  also  occur.  On  the  other  hand,  the  uratic  deposits  may 
undergo  complete  solution,  and  the  joint  be  left  in  an  apparently  normal 
condition.     The  urine  of  chronic  gout  is  somewhat  increased  in  quantity, 


GOUT.  465 

and  is  of  lower  specific  gravity  and  somewhat  paler  than  normal.  The 
amount  of  uric  acid  eliminated  is  diminished.  A  trace  of  albumin  is  fre- 
quently present,  and  permanent  albuminuria  is  a  fairly  common  occurrence 
in  confirmed  gout.  Before  an  attack  of  gout  the  output  of  uric  acid  is 
low,  and  is  also  diminished  in  the  early  part  of  the  attack.  The  excretion 
of  phosphoric  acid  in  the  urine  is  stated  to  correspond  very  closely  to  that 
of  uric  acid,  being  low  before  and  during  the  early  part  of  the  paroxysm, 
but  rising  as  the  attack  passes  off.  Oxaluria  is  of  fairly  common  occur- 
rence in  connection  with  gouty  attacks.  Changes  in  the  heart  and 
circulation,  consequent  on  gouty  affections  of  the  kidneys,  are  indicated  by 
hypertrophy  of  the  left  ventricle,  a  strong  cardiac  impulse,  displacement 
of  the  apex  beat  to  the  left,  and  accentuation  of  the  aortic  second  sound. 
The  pulse  is  of  high  tension,  and  the  arteries  are  hard,  tortuous,  and  some- 
times atheromatous.  Under  such  conditions  a  cerebral  haemorrhage  may 
occur.  Attacks  of  true  angina  pectoris,  associated  with  arterial  degenera- 
tion and  softening  of  the  walls  of  the  heart,  occasionally  occur  in  gouty 
subjects. 

Saturnine  or  lead  gout. — Chronic  lead  poisoning  gives  rise  to  both 
chronic  kidney  disease  and  gout.  The  liability  of  those  suffering  from  chronic 
plumbism  to  be  attacked  with  gout,  is  probably  due  to  the  action  of  lead  salts 
on  the  kidney  epithelium  causing  a  diminution  in  the  excretion  of  uric 
acid,  so  that  an  absorption  of  the  non-excreted  portion  takes  place  from 
the  kidneys  into  the  general  circulation.  The  patient  suffering  from  satur- 
nine gout,  unlike  the  majority  of  sufferers  from  inherited  gout,  is  pale, 
thin,  and  anaemic.  If  the  lead  poisoning  has  been  of  short  duration,  the 
lesions  may  yield  to  treatment,  but  after  a  prolonged  absorption  of  lead 
into  the  system  the  kidney  condition  is  generally  incurable. 

Irregular  gout. — Gout  appearing  in  a  situation  other  than  a  joint  is 
regarded  as  irregular  or  abarticular.  Irregular  gout  may  accompany 
arthritic  gout,  or  may  take  its  place,  or  may  alternate  with  it,  but  more 
frequently  it  occurs  among  those  who  have  never  suffered  from  gout  in  the 
joints,  but  who  are  predisposed  to  gout  either  by  inheritance  or  by  mode  of 
life.  The  most  important  points  to  attend  to  in  the  diagnosis  of  irregular 
gout  are  the  question  of  heredity,  the  habits  of  the  patient,  the  nature  of 
the  attack,  a  careful  examination  of  the  urine,  and,  if  possible,  of  the  blood 
or  blood  serum ;  and,  lastly,  the  successful  reaction  to  therapeutic  remedies. 
Probably  all  forms  of  irregular  gout  are  due  to  the  precipitation  in  the 
crystalline  form  of  sodium  biurate  in  the  organ  or  tissue  affected.  Irregular 
gout  may  affect — the  alimentary  tract,  causing  pharyngitis,  cesophagis- 
mus,  dyspepsia,  or  gastro-intestinal  catarrh;  the  air  passages  and  lungs, 
causing  laryngitis,  tracheitis,  bronchitis,  or  asthma;  the  heart  and 
vessels,  causing  cardiac  irritability,  anginal  attacks,  or  phlebitis;  the 
nervous  system,  causing  migraine,  neuralgia,  neuritis,  or  mental  depression ; 
the  genito-urinary  system,  causing  gouty  kidney,  or  uric  acid  gravel,  or 
urethritis;  the  skin,  causing  eczema,  herpes,  pruritus,  or  urticaria;  and 
the  eye,  causing  gouty  inflammation  of  any  of  the  structures  of  the  eye,  * 
— conjunctivitis  and  iritis  are  the  two  commonest  eye  affections  caused  by 
the  gouty  condition.  Irregular  gout  may  also  manifest  itself  as  glycosuria 
or  diabetes. 

Retrocedent  or  metastatic  gout. — This  form  of  gout  occurs  when  a 

sudden  subsidence  of  the  inflammation  in  a  gouty  joint  is  succeeded  by  the 

development  of  the  disease  in  one  or  more  of  the  internal  organs,  such  as 

the  stomach,  intestines,  heart,  or  liver.     Such  attacks  frequently  follow  an 

vol.  I. — 30 


466  GENERAL  DISEASES. 

exposure  to  cold  while  suffering  from  an  articular  attack,  and  especially 
after  indiscretion  in  diet.  If  the  attacks  rapidly  shift  their  position,  the 
affection  is  termed  flying  gout.  Attacks  of  retrocedent  gout  have  not  un- 
commonly followed  the  baneful  practice  of  suddenly  plunging  a  gouty  foot 
into  cold  water.  It  is  quite  possible  that  the  attacks  are  caused  by  a 
deposition  of  the  crystalline  sodium  biurate  in  the  affected  viscus,  and  that 
this  crystalline  biurate  acts  as  a  mechanical  irritant,  and  so  produces 
inflammation  of  the  organ.  On  the  other  hand,  the  attacks  may  simply  be 
of  nervous  reflex  origin,  due  to  vasomotor  disturbance  producing  a  con- 
dition of  hyperemia  or  congestion  of  the  affected  viscus.  The  following 
are  the  principal  forms  of  retrocedent  gout,  with  the  symptoms  indicative 
of  the  sudden  transference  of  the  attack  to  the  affected  viscus : — 

Stomach. — The  symptoms  usually  consist  of  severe  pain  in  the  stomach, 
accompanied  generally  by  vomiting  and  a  feeling  of  general  oppression, 
depression,  and  faintness.     Palpitation  may  occur. 

Intestines. — The  usual  symptoms  are  severe  abdominal  pain,  vomiting, 
tympanites,  and  constipation. 

Heart. — The  symptoms  are  severe  palpitation,  pain  in  the  region  of  the 
heart,  a  sensation  of  constriction  of  the  chest,  dyspnoea,  a  small,  feeble 
pulse,  and  great  anxiety.     Syncopal  attacks  may  occur. 

Brain. — Apoplexy  is  the  most  frequent  symptom.  Congestion  of  the 
brain  or  meninges  may  occur,  and  may  be  followed  by  headache,  stupor, 
convulsions,  delirium,  and  occasionally  by  maniacal  attacks.  Transient 
attacks  of  aphasia,  amnesia,  and  hemiplegia  sometimes  occur,  and  are  pro- 
bably due  to  congestion  of  the  brain. 

Diagnosis. — The  well-marked  symptoms  attending  an  attack  of 
acute  gout  render  the  diagnosis  easy.  The  subacute  and  chronic  forms 
of  gout  may  be  confounded  with  rheumatism,  rheumatoid  arthritis,  or 
with  synovitis  of  traumatic,  pysemic,  or  gonorrhoeal  origin.  The  appear- 
ance of  the  joint,  the  discovery  of  tophi,  and  the  family  history  are  the 
main  points  on  which  to  rely.  The  blood  may  also  be  examined  for  uric 
acid  by  the  following  method,  known  as  Garrod's  thread  test: — About 
2  drms.  of  the  serum  furnished  by  the  blood,  on  standing,  or  of  the  fluid 
raised  by  a  blister,  are  placed  in  a  large  watch-glass,  acidulated  with  acetic 
acid  to  set  free  the  uric  acid,  and  an  ultimate  fibre  from  a  piece  of  linen 
cloth  immersed  in  the  fluid ;  the  watch-glass  is  then  covered  over  and  left 
in  a  warm  room.  When,  by  evaporation,  the  serum  has  been  brought  to 
the  consistence  of  a  thin  jelly,  the  fibre,  still  on  the  watch-glass,  is 
examined  under  a  low  power  of  the  microscope,  when,  if  obtained  from  a 
gouty  subject,  it  will  be  found  to  be  studded  with  crystals  of  uric  acid. 
The  important  subject  of  the  differential  diagnosis  of  gout,  rheumatism,  and 
rheumatoid  arthritis  is  dealt  with  under  the  last-mentioned  head. 

Prognosis. — If  no  complications  arise,  if  the  attacks  are  not  too 
frequent,  and  if  no  serious  amount  of  albuminuria  occurs,  the  disease  is  not 
likely  to  materially  shorten  life,  especially  if  the  patient  is  amenable  to 
proper  treatment  and  discipline.  The  prognosis,  in  cases  of  irregular  gout 
affecting  the  heart,  and  in  cases  of  retrocedent  gout,  is  much  graver. 

Treatment. — No  routine  treatment  can  be  adopted  which  is  suitable 
to  all  cases.  The  treatment  of  individual  cases  must  be  regulated  accord- 
ing to  the  nutritional  condition  of  the  patient,  his  habits,  surroundings, 
and  mode  of  life. 

General  management. — It  should  have  for  its  aim  the  following 
objects: — The   treatment  of  the  gouty  paroxysm,  and  the  relief  of  the 


GOUT  467 

pain  as  speedily  as  possible ;  the  treatment  of  the  subacute  or  chronic 
condition,  and  the  prevention  of  the  recurrence  of  an  attack,  which  may 
be  effected  by  the  promotion  of  the  elimination  of  uric  acid,  by  checking 
any  excessive  formation  of  uric  acid  that  occurs  in  some  subjects,  and 
by  careful  attention  to  diet  and  general  hygiene;  and  the  treatment  of 
the  affected  joint  or  joints,  with  the  object  of  removing  the  uratic  deposits, 
and  of  preventing  permanent  deformity.  A  careful  examination  of  the 
urine  should  always  be  made,  and  it  is  especially  important  to  ascertain 
whether  the  kidney  affection  is  in  the  transient  or  organic  stage.  The 
indications  that  the  gouty  affection  of  the  kidneys  is  passing  from  the 
transient  into  the  organic  condition  are  the  existence  of  a  certain  amount 
of  polyuria,  a  low  specific  gravity  of  urine — usually  from  1007  to  1016 — 
the  presence  of  a  small  quantity  of  albumin  and  of  a  few  granular  casts,  if 
a  careful  microscopical  examination  is  made  after  centrifuging  the  urine, 
and  a  diminished  daily  excretion  of  uric  acid  and  generally  of  urea.  It  is 
desirable  before  commencing  treatment,  and  from  time  to  time  during 
treatment,  to  ascertain  the  amount  of  uric  acid  that  is  being  daily  eliminated 
in  proportion  to  the  body-weight  of  the  patient.  This  determination  must 
be  made  on  a  sample  of  the  mixed  urines  of  twenty-four  hours,  as  the  mere 
determination  of  the  percentage  of  uric  acid  in  a  casual  sample  of  urine 
constitutes  no  guide  to  the  actual  amount  that  is  being  daily  excreted. 

Treatment  of  acute  gout. — Local. — If  the  gouty  paroxysm  occurs,  as 
it  most  frequently  does,  in  a  great  toe  joint  or  foot,  the  limb  should  be 
slightly  elevated  above  the  level  of  the  body,  and  a  cradle  arranged  to  take 
the  weight  of  the  bedclothes  off  the  affected  part.  To  alleviate  the  severe 
pain,  a  pack  of  cotton-wool  should  be  arranged  round  the  affected  joint,  and 
should  be  saturated  with  a  warm  lotion  containing  sodium  carbonate, 
belladonna  liniment,  and  laudanum.  The  pack  should  be  changed  every 
eight  or  twelve  hours.  No  attempt  at  local  depletion — such  as  the  appli- 
cation of  leeches  to  the  inflamed  joint,  blistering,  or  incisions — should  on 
any  account  be  made.  Nor  should  cold  bathing  or  cold  application  to  the 
joint  be  attempted.  For  the  internal  treatment  of  acute  gout,  colchicum  is 
a  most  valuable  drug.  It  should  be  especially  used  for  acute  gout,  and  for 
subacute  attacks  supervening  on  chronic  gout,  as,  if  used  continuously, 
tolerance  is  apt  to  be  acquired,  and  then  the  drug  ceases  to  act.  At  the 
commencement  a  large  dose  of  30  to  40  minims  of  colchicum  wine  should 
be  given,  followed  by  a  mixture  containing  in  each  dose  10  to  20  minims 
of  the  wine,  with  from  40  to  60  grs.  of  citrate  of  potassium,  which  should 
be  taken  three  times  a  day.  The  citrate  of  potassium  is  given  for  its  com- 
bined properties  of  acting  as  a  diuretic  and  of  diminishing  the  acidity  of 
the  urine.  Colchicum  reduces  the  gouty  inflammation,  relieves  the  pain, 
and  shortens  the  attack.  It  is  a  powerful  direct  cholagogue,  and  it  is 
probably  owing  to  its  action  on  the  liver,  by  inhibiting  the  formation  of 
glycocine,  and  so  diminishing  the  formation  of  uric  acid  in  the  kidneys, 
that  the  efficacy  of  colchicum  in  mitigating  the  severity  of  the  pain  and 
relieving  an  attack  of  gout  is  due.  From  3  to  4  grs.  of  blue  pill  should  be 
given  the  first  night,  and  should  be  followed  by  a  dose  of  Epsom  salts  in 
the  morning.  In  the  employment  of  purgatives  for  gouty  patients  the 
great  object  is  not  to  produce  powerful  purgation,  but  to  relieve  portal 
congestion.  A  very  useful  pill  is  one  containing  either  2  grs.  of  euonymin 
or  \  gr.  of  podophyllin,  combined  with  1  gr.  of  extract  of  hyoscyamus 
and  11  gr.  of  the  compound  extract  of  colocynth.  If  the  pain  of  an 
acute  attack  of  gout  is  so  severe  as  to  prevent  sleep,  10  grs.  of  chloral, 


468  GENERAL  DISEASES. 

sulphonal,  trional,  or  phenacetin  may  be  given,  or  a  dose  of  1  gr.  of  extract 
of  hyoscyamus,  given  with  blue  pill  at  night,  will  in  some  cases  act  as  a 
very  useful  anodyne.  It  is  doubtful  whether  salicylates  are  of  any  use  in 
the  treatment  of  true  gout. 

Dietetic — For  the  first  day  or  two  of  an  acute  attack  the  patient 
should  be  restricted  to  a  milk  diet,  which  may  consist  of  milk,  arrowroot 
and  milk,  bread  and  milk,  milk  puddings  made  with  rice,  sago,  or 
tapioca,  and  tea  made  with  boiling  milk  instead  of  with  water.  Weak 
tea,  with  cold  toast  thinly  buttered,  may  also  be  taken.  The  free  drinking 
of  hot  or  cold  water,  or  of  some  mineral  water  free  from  sodium  salts, 
should  be  encouraged.  During  the  acute  stage  no  alcohol  should  be 
given,  unless  there  are  strong  reasons  for  its  administration,  such  as  a 
weak  action  of  the  heart,  and  a  feeble,  irregular  pulse,  when  a  little 
well-matured  whisky,  diluted  with  an  aerated  water,  will  prove  the  best 
form  of  alcohol.  Beef -tea,  and  any  of  the  meat  extracts  or  essences,  should 
be  avoided  at  all  times  by  gouty  patients,  owing  to  the  tendency  they  have 
to  irritate  the  kidneys,  and  so  to  interfere  with  the  elimination  of  uric 
acid.  "With  the  subsidence  of  the  acute  attack,  the  patient  may  return  to 
a  more  liberal  diet. 

Treatment  of  chronic  gout. — The  excessive  formation  of  uric  acid 
may  be  checked  by  careful  attention  to  diet  and  regimen,  by  the  promotion 
of  the  metabolism  of  the  liver,  and  by  the  relief  of  congestion  of  the  portal 
system.  In  addition  to  colchicum,  which  may  be  given  in  small  doses, 
guaiacum  may  be  very  usefully  administered  as  an  alterative,  which 
stimulates  the  metabolism  of  the  liver,  and  also  affords  relief  to  the  portal 
system.  From  5  to  10  grs.  of  guaiacum  resin  should  be  given  in  cachets 
two  or  three  times  a  day.  If  constipation  occur,  a  sulphur  and  guaiacum 
tablet,  or  a  dose  of  compound  liquorice  powder,  should  be  taken  at  night. 
An  occasional  dose  of  blue  pill  and  euonymin,  followed  by  a  purge  of 
Epsom  salts,  will  be  found  useful.  The  elimination  of  uric  acid  may  be 
promoted  by  encouraging  free  diuresis,  by  the  drinking  of  sufficient 
quantities  of  water,  and  by  the  administration  of  citrate  of  potassium, 
which  increases  the  volume  of  the  urine,  and  at  the  same  time  diminishes 
its  acidity.  The  use  of  the  citrate  of  potassium  may  with  advantage  be 
pushed  until  moderate  alkalinity  of  the  urine  is  produced.  A  patient 
suffering  from  gout  should  avoid,  as  far  as  possible,  the  use  of  common  salt 
at  table,  on  account  of  the  power  that  it  possesses  of  hastening  the 
precipitation  of  sodium  biurate. 

To  reduce  the  chronic  inflammatory  thickening  of  the  fibrous  tissues 
around  gouty  joints,  iodide  of  potassium  may  be  given  in  doses  of  5  to 
10  grs.  three  times  a  day,  and  may  usefully  be  combined  with  from  5  to  10 
minims  of  tincture  of  iodine.  Careful  massage  and  gentle  exercise  of  the 
stiffened  joints  should  be  employed,  but  only  when  convalescence  is  fairly 
established ;  massage  and  muscular  movements  increase  the  flow  of  lymph 
in  the  lymph  channels,  and  so  tend  to  promote  the  removal  of  uratic 
deposits,  and  to  increase  general  metabolism.  If  the  oedema  around  a  joint 
should  persist,  the  hot  douche,  followed  by  sponging  with  a  cold,  strong 
solution  of  common  salt,  will  be  found  serviceable.  The  thermal  baths  of 
Bath,  Buxton,  Aix-les-Bains,  as  well  as  other  spas,  and  mud  baths,  are  useful 
in  the  treatment  of  cases  of  chronic  articular  gout.  The  lithium  salts,  which 
have  for  some  time  had  a  reputation  of  being  solvents  of  gouty  deposits, 
probably  do  not  possess  any  such  power,  but  since  they  are  powerful 
diuretics,  they  may,  on  that  account,  be  of  some  use  in  the  treatment  of 


GOVT.  469 

chronic  gout.  They  should  never,  however,  be  given  in  sufficient  quantities 
to  keep  the  urine  alkaline,  as  their  depressing  effect  in  such  doses  is  too 
great.  After  convalescence,  as  much  exercise  as  possible,  short  of  fatigue 
and  discomfort,  should  be  taken  in  the  open  air.  Cycling  is  an  excellent 
exercise  for  the  gouty,  since  it  furnishes  good  muscular  movement  in  the 
open  air,  without  the  gouty  joints  having  to  bear  the  weight  of  the  body. 

Treatment  of  retrocedent  gout. — If  the  symptoms  are  urgent,  some 
brandy  should  be  given,  and  if  necessary,  morphine  injected  hypo- 
dermically,  provided  marked  albuminuria  does  not  exist.  If  the  metastatic 
seizure  affects  either  the  heart  or  brain,  it  may  be  desirable  to  reinduce 
an  attack  of  articular  gout  by  placing  the  feet  in  a  hot  mustard  and  water 
bath.  For  the  treatment  of  the  cardiac  form,  heart  tonics  and  brandy 
should  be  administered,  and  a  mustard  leaf  applied  to  the  epigastrium.  If 
an  anginal  attack  occurs,  then,  in  addition,  a  dose  of  nitroglycerin  should 
be  given  at.  once,  or  an  inhalation  of  nitrite  of  amyl  employed.  For  the 
treatment  of  the  cerebral  form,  if  the  patient  is  plethoric,  if  the  pulse  is 
hard,  and  stupor  or  coma  supervene,  venesection  should  be  performed, 
and  from  8  to  16  oz.  of  blood  withdrawn ;  in  less  urgent  cases,  six 
leeches  may  be  applied  to  the  mastoid  region.  For  the  treatment  of  the 
gastro-intestinal  form  of  retrocedent  gout,  a  mustard  leaf  should  be  applied 
to  the  epigastrium,  and  a  mixture  containing  bismuth  subcarbonate, 
sodium  bicarbonate,  and  hydrocyanic  acid  should  be  given. 

Treatment  of  irregular  gout. — One  form  of  irregular  gout,  the  gouty 
heart,  is  associated  with  fatty  degeneration  of  the  cardiac  walls,  and  is 
generally  evidenced  by  vertigo,  faintness,  palpitation,  irregular  pulse, 
insomnia,  and  slight  anginal  attacks.  The  treatment  should  be  rest  in  the 
recumbent  position  ;  and  a  small  dose  of  blue  pill  or  calomel,  followed  by  a 
purge  of  Epsom  salts,  should  be  administered.  A  mixture  containing  con- 
vallaria  and  strychnine  may  be  given,  and  if  anginal  attacks  occur, 
nitroglycerin  or  erythrol  tetranitrate  may  be  given  by  the  mouth,  or  in- 
halations of  nitrite  of  amyl  employed.  The  patient  must  be  carefully  dieted ; 
and  graduated  exercise,  at  first  of  a  pafssive  nature,  such  as  massage,  and 
later  of  an  active  kind,  such  as  resistance  exercises,  may  be  very  beneficial. 
For  the  treatment  of  gouty  phlebitis,  which  is  a  fairly  common  form  of 
irregular  gout,  the  patient  should  be  kept  in  the  recumbent  position,  and 
any  sudden  movement  of  the  affected  limb  must  be  prevented,  on  account 
of  the  danger  of  detaching  a  portion  of  the  thrombus,  and  the  occurrence 
of  consequent  embolism  of  the  pulmonary  artery.  Equal  parts  of  glycerin 
and  extract  of  belladonna  should  be  smeared  over  the  affected  part,  and  a 
linseed  poultice,  with  some  of  the  glycerin  and  belladonna  spread  on  the 
surface,  should  be  applied  and  renewed  every  six  hours.  In  addition,  the 
ordinary  treatment  of  the  gouty  state  must  be  resorted  to.  For  the 
treatment  of  gouty  sciatica,  the  patient  must  be  kept  in  the  recumbent 
position,  and  in  severe  cases  the  pain  should  be  relieved  by  a  hypodermic 
injection  of  morphine.  Ammonium  chloride,  in  doses  of  30  to  40  grs. 
three  times  a  day,  is  a  very  useful  drug  in  the  treatment  of  this  complaint. 
Two  grs.  of  hydrobromide  of  quinine  should  also  be  given  in  a  pill,  two  or 
three  times  a  day,  and,  in  addition,  the  ordinary  treatment  of  the  gouty 
state  will  probably  have  to  be  resorted  to. 

Treatment  of  gouty  glycosuria  and  gouty  diabetes.  —  Dietetic 
treatment  should  be  resorted  to,  without,  however,  restricting  the  diet  too 
much.  An  excessively  nitrogenous  diet  is  to  be  avoided  as  tending  to 
accentuate  the  gouty  condition,  but  no  hard-and-fast  rules  as  to  the  amount 


47o  GENERAL  DISEASES. 

of  diet  can  be  laid  down.  Each  case  must  be  treated  by  ascertaining  what 
amount  of  proteids,  fats,  and  carbohydrates  are  best  borne  by  the  individual. 
Toasted  bread,  milk,  and  milk  puddings  made  with  rice,  sago,  and  tapioca, 
are  generally  permissible  in  this  form  of  glycosuria.  The  best  test  of  the 
suitability  of  the  diet  is  the  fact  that  the  weight  of  the  patient  is  not 
diminishing,  while  at  the  same  time  the  excretion  of  sugar  is  becoming 
less.  A  pill,  containing  1  gr.  of  blue  pill,  1  gr.  of  acetic  extract  of 
colchicum,  and  2  grs.  of  euonymin,  should  be  given  every  other  night ;  and 
a  mixture  containing  30  grs.  of  ammonium  chloride  and  15  minims  of 
dilute  nitro-hydrochloric  acid  should  be  taken  three  times  a  day.  The 
mineral  waters  best  suited  for  the  treatment  of  gouty  glycosuria  and 
diabetes  are  those  of  Carlsbad,  Kissingen,  Leamington,  Llandrindod, 
Marienbad,  Neuenahr,  and  Vichy. 

Preventive  treatment  of  gout. — Whatever  promotes  the  elimination 
of  uric  acid,  and  so  prevents  its  absorption  into  the  general  circulation, 
tends  to  prevent  the  occurrence  of  gout.  This  can  be  effected  by — the 
promotion  of  increased  diuresis ;  the  production,  at  all  events  inter- 
mittently, of  a  moderate  degree  of  alkalinity  of  the  urine ;  and  by 
stimulation  of  the  metabolism  of  the  liver,  and  of  the  kidney  cells  engaged. 
in  the  excretion  of  uric  acid.  The  first  effect  can  be  secured  by  the 
patient  drinking  a  sufficient  quantity  of  ordinary  water,  or  of  a  suitable 
mineral  water ;  the  second  object  is  attained  by  the  consumption  of 
sufficient  quantities  of  vegetable  food,  and  by  the  occasional  administration 
of  citrate  of  potassium ;  and  the  third,  by  the  administration  of  suitable 
cholagogues,  such  as  guaiacum,  and  an  occasional  euonymin  and  blue  pill. 
Careful  attention  should  be  given  to  diet.  Eegular  habits  and  sufficient 
exercise  should  be  encouraged,  and  constipation  should  be  avoided. 

Diet  in  gout. — A  rational  mixed  diet  is  the  one  best  suited  for  gouty 
patients.  The  assumption  that  a  purely  vegetable  diet  is  the  best  for 
the  gouty  is  erroneous,  since  it  makes  no  difference  as  regards  the 
production  of  uric  acid,  whether  the  proteid  matter  be  of  animal  or 
vegetable  origin ;  but  since  animal  tissues  are  so  much  richer  in  proteids 
than  a  vegetable  diet,  the  amount  of  the  former  taken  by  the  gouty  should 
be  strictly  limited.  Due  consideration  should  always  be  given  to  a  patient's 
experience  of  what  articles  of  diet  disagree  and  agree  with  him.  It  is 
important  that  a  gouty  patient  should  take  a  sufficiency  of  water  to  drink, 
so  that  the  various  organs  are  well  flushed,  the  removal  of  the  gouty 
deposits  encouraged,  and  the  specific  gravity  of  the  urine  kept  moderately 
low.  The  quantities  of  fluids  taken  in  the  twenty-four  hours  should  not  be 
less  than  3|  pints,  and  may  even  with  advantage  reach  to  4|  pints.  It  is 
an  excellent  custom  for  a  gouty  person  to  slowly  sip  half  a  pint  to  a  pint 
of  hot  water  in  the  morning  immediately  after  rising,  and  at  night  before 
retiring  to  bed ;  if  desired,  the  water  may  be  flavoured  with  a  slice  of 
lemon  peel. 

For  breakfast,  a  selection  may  be  made  from  the  following  articles 
of  diet :— Porridge  and  milk,  whiting,  sole,  plaice,  fat  bacon,  and  eggs 
cooked  in  various  ways.  Dry  toast  thinly  buttered,  and  tea  infused  for 
three  minutes,  should  be  taken  with  breakfast.  At  lunch  and  dinner, 
no  soup  should  be  taken.  The  varieties  of  fish  most  suitable  to  the 
gouty  are  whiting,  sole,  turbot,  and  plaice.  Meat  should  be  taken  at 
only  one  meal,  and  then  in  moderate  quantity.  Beef,  mutton,  chicken, 
turkey,  pheasant,  and  calf's  sweetbread  are  admissible.  Salted  meat, 
salted  and  smoked  fish,  shell-fish,  and  articles  of  food  pickled  in  vinegar, 


GOUT.  471 

should  be  avoided.  Two  vegetables  should  be  taken  at  both  lunch  and 
dinner,  and  in  abundant  quantities.  The  vegetables  that  should  be 
avoided  by  the  gouty  are  asparagus,  tomatoes,  and  green  peas.  Any  of 
the  other  ordinary  vegetables  may  be  taken,  of  which  the  most  useful  are 
spinach,  Brussels  sprouts,  French  beans,  cabbage,  turnip-tops,  turnips,  and 
celery.  Stewed  or  baked  fruits  may  with  advantage  be  taken  every  day  at 
one  meal,  and  a  milk  pudding  at  the  other  meal.  Rich  pastry  and  all  rich 
sweets  should  be  avoided. 

As  regards  the  employment  of  alcohol,  if  the  gouty  person  be  of  robust 
habit  of  body,  total  abstinence  is  best.  If,  however,  the  cardiac  action 
be  weak  and  failing,  moderate  quantities  of  alcohol  should  certainly  be 
allowed.  In  cases  of  chronic  gout,  a  moderate  amount  of  alcohol  may  be 
necessary  for  the  promotion  of  digestion.  A  tablespoonful  of  matured 
whisky,  freely  diluted,  constitutes  the  best  form  of  alcohol.  Of  wines, 
light  but  sound  clarets,  Moselles,  and  hocks  are  least  open  to  objection. 
Port,  burgundy,  champagne,  ale,  and  stout  should  be  avoided  by  the  gouty. 

Mineral  waters  in  the  treatment  of  gout. — The  value  of  a  given 
mineral  water  in  the  treatment  of  gout  depends  greatly  on  the  main  object 
with  which  it  is  taken — whether  to  remove  gouty  deposits,  or  to  stimulate 
the  action  of  a  sluggish  liver  and  to  relieve  portal  congestion,  or  for  the 
treatment  of  gouty  dyspepsia,  or  to  relieve  the  bowels  in  cases  of  torpor 
and  gastro-intestinal  catarrh,  or  to  act  on  the  kidneys,  or  to  relieve  gouty 
affections  of  the  skin.  The  use  of  a  mineral  water,  so  far  as  its  employ- 
ment with  the  object  of  removing  gouty  deposits  is  concerned,  lies  solely  in 
its  watery  constituent,  and  does  not  in  any  way  depend  on  the  mineral 
constituents  dissolved  in  it.  For  such  a  purpose,  the  springs  which  contain 
no  sodium  salts,  or  traces  only,  are  the  ones  suitable  for  such  cases ;  these 
are  the  simple  waters  classified  in  the  first  group.  In  cases  of  sluggish 
action  of  the  liver,  of  gastro-intestinal  catarrh  and  torpor,  of  gouty  dys- 
pepsia, and  of  other  forms  of  irregular  gout,  mineral  waters  containing 
sodium  salts  are  beneficial,  owing  to  the  action  of  these  salts  as  hepatic 
and  gastro-intestinal  stimulants.  The  various  mineral  waters  used  in  the 
treatment  of  gout  may  be  classified  into  the  six  following  groups  : — 

The  simple  waters,  or  waters  comparatively  free  from  sodium,  salts. — 
These  are  the  waters  that  are  especially  useful  for  the  removal  of  uratic 
deposits  in  the  joints  and  tissues.  The  principal  waters  of  this  class  are 
those  of  Buxton,  Bath,  Strathpeffer,  Contrexeville,  Aix-les-Bains,  Pfaffers, 
Gastein,  Wildbad,  and  Vittel. 

The  single  alkaline  waters. — These  contain  sodium  bicarbonate,  and 
are  useful  for  the  treatment  of  hepatic  congestion,  dyspepsia,  and  gastro- 
intestinal catarrh.  The  principal  waters  of  this  class  are  those  of  Vichy, 
Vals,  Neuenahr,  Salzbrunn,  and  Fachingen. 

The  alkaline  sulphated  waters. — These  contain  sodium  bicarbonate 
and  sulphate,  and  generally  a  moderate  proportion  of  sodium  chloride,  and 
are  useful  for  the  treatment  of  the  same  class  of  disorders  as  mentioned  in 
the  previous  group.  The  principal  waters  of  this  class  are  those  of 
Carlsbad,  Marienbad,  Tarasp-Schuls,  Cheltenham,  and  Leamington. 

The  alkaline  muriated  waters. — These  contain  sodium  bicarbonate  and 
chloride,  and  are  useful  for  the  treatment  of  gouty  dyspepsia,  and  of  gouty 
catarrhal  affections  of  the  respiratory  organs.  The  principal  waters  of  this 
class  are  those  of  Ems,  Boyat,  Assmannshausen,  and  La  Bourboule. 

The  muriated  waters. — These  contain  sodium  chloride  as  their  prin- 
cipal constituent,  and  are  useful  for  the  treatment  of  gastro-intestinal  and 


472  GENERAL  DISEASES. 

hepatic  gout,  and  gouty  dyspepsia.  The  principal  waters  of  this  class 
are  those  of  Homburg,  Wiesbaden,  Kissingen,  Baden-Baden,  Nauheim, 
Llandrindod,  "Woodhall  Spa,  and  Llangammarch  Wells. 

The  sulphur  waters. — These  contain  sulphur,  either  in  the  form  of 
sulphuretted  hydrogen  only,  or,  in  addition,  some  of  the  sulphur  may  exist 
in  the  form  of  the  sulphides  of  calcium,  magnesium,  and  sodium.  They  are 
useful  in  the  treatment  of  gouty  skin  affections.  The  principal  waters  of 
this  class  are  those  of  Harrogate,  Strathpeffer,  Aix-les-Bains,  Aix-la- 
Chapelle,  Baden,  Llandrindod,  and  Weilbach. 

A.  P.  LUFF. 


ACUTE  EHEUMATISM,  OE  EHEUMATIC  FEVEE. 

An  acute  systemic  disease,  probably  dependent  upon  an  unknown  in- 
fective agent,  and  characterised  by  arthritic  and  cardiac  manifestations, 
as  well  as  a  tendency  to  inflammation  of  other  fibrous  tissues. 

Etiology. — Acute  rheumatism  is  essentially  a  disease  of  adolescence 
and  of  early  adult  life,  although  no  period  of  life,  except  early  infancy,  is 
exempt.  In  early  life,  up  to  the  ages  of  18  or  20,  and  especially  among 
children,  the  disease  is  somewhat  more  common  in  females ;  but,  taking 
all  ages  together,  males  are  affected  oftener,  owing,  no  doubt,  to  the 
occupations  of  men  involving  a  greater  tendency  to  the  disease,  from 
exposure  to  cold  and  wet. 

That  there  is  some  hereditary  transmission  of  a  liability  to  this  disease 
is  generally  believed.  Cheadle  considers  that  the  tendency  to  rheumatism 
is  transmitted  as  strongly  as  the  tendency  to  gout.  Whilst  admitting  the 
probability  of  some  inherited  tendency  to  rheumatism,  the  writer's 
experience  is  that  it  is  not  nearly  so  great  as  in  cases  of  gout.  Chill  is 
the  most  important  factor  in  determining  an  attack  of  acute  rheumatism. 
The  chill  may  result  from  exposure  to  cold,  or  from  a  wetting,  or  from  a 
sudden  change  of  temperature.  Those  occupations  involving  exposure  to 
cold  and  to  great  changes  of  temperature,  are  predisposing  causes  to 
rheumatic  fever.  One  attack  of  acute  rheumatism  does  not  afford  immunity 
from  a  future  attack ;  on  the  contrary,  the  individual  is  predisposed  by 
one  attack  to  subsequent  attacks.  Acute  rheum tism  is  more  frequent  in 
temperate,  subtropical,  and  humid  climates.  In  this  country  it  is  most 
prevalent  in  the  autumn.  According  to  Newsholme,  it  prevails  most  in 
dry  years,  when  the  subsoil  water  is  abnormally  low,  and  the  temperature 
of  the  earth  is  high. 

Pathology. — The  view  that  is  rapidly  gaining  ground  is,  that  the 
symptoms  of  acute  rheumatism  are  due  to  an  infective  organism,  and  to 
its  elaborated  toxine  or  toxines.  This  view  is  supported  by  the  fact  that 
there  is  a  marked  resemblance  between  the  entire  course  of  rheumatic 
fever  and  that  of  an  infective  disease,  as  seen  in  the  character  of  the 
fever,  the  involvement  of  the  joints,  the  liability  to  endocarditis  and 
pericarditis,  the  sweats,  the  ansemia,  and  the  tendency  to  relapse.  The 
proof  that  is  wanting  that  the  disease  is  infective  in  its  nature,  is  the 
association  of  a  specific  micro-organism  with  the  complaint.  Achalme  has 
described  a  bacillus,  similar  in  appearance  to  that  of  anthrax,  which  he 
found  in  the  heart  blood  and  in  the  cerebro-spinal  fluid  of  two  Cases  of 
acute  rheumatism,  which  were  examined  soon  after  death ;  he  also  found 


ACUTE  RHEUMATISM,  OR  RHEUMATIC  FEVER.       473 

the  same  bacillus  in  the  blood  of  living  cases.  Whether  this  is  the  specific 
organism  of  rheumatic  fever,  is  doubtful.  Poynton  and  Paiue  have  recently 
discovered  a  diplococcus  which  is  present  in  the  blood  and  tissues  of 
patients  suffering  from  acute  rheumatism,  and  which  causes  symptoms 
resembling  rheumatic  fever,  with  endocarditis,  in  animals.  Newsholme  con- 
siders that  the  general  evidence  is  in  favour  of  a  microbic  matcries  rnorbi, 
which  he  thinks  is  essentially  a  soil  organism.  In  support  of  his  view,  he 
refers  to  the  occasional  concentration  of  the  disease  in  epidemic  form  in  cer- 
tain cities,  or  in  streets,  and  even  in  certain  houses,  and  also  to  many  of  the 
clinical  features  of  the  disease  being  in  favour  of  its  infective  nature,  namely, 
the  mode  of  onset  with  aching,  the  shivering  in  many  cases,  the  sore  throat, 
the  progress  of  the  fever,  its  complications,  and  its  tendency  to  relapse. 
He  thinks  that  the  channel  of  infection  is  the  tonsils  or  some  part  of  the 
naso-pharynx,  for  tonsillitis  is  very  common  among  cases  of  rheumatic 
fever,  and  that  the  well-known  influence  of  injury,  fatigue,  and  chill  is  to 
lessen  the  resistance  of  the  individual.  The  frequency  with  which 
rheumatic  fever  occurs  in  particular  houses  tends  to  support  the  infective 
theory  of  the  disease,  and  Lees  even  considers  that  the  disease  is  probably 
a  house  disease,  and  that  its  prevalence  would  be  diminished  if  every  house 
had  an  impermeable  basement.  Newsholme  inclines  to  the  opinion  that  a 
low  level  of  ground  water  is  an  indication  of  certain  conditions  of  dryness 
and  temperature  of  the  subsoil  favourable  to  the  growth  of  the  telluric 
contagium  of  acute  rheumatism,  which  view  is  supported  by  the  fact  that 
the  disease  is  most  common  in  the  autumn,  reaching  its  maximum  in 
October.  In  support  of  the  theory  that  acute  rheumatism  is  an  infective 
disease,  Newsholme  has  shown  that  the  rate  both  of  the  mortality  and  of 
the  frequency  of  the  disease  fluctuate  in  a  manner  very  similar  to  those 
of  such  infectious  diseases  as  scarlet  fever  and  erysipelas. 

Two  theories  as  to  the  causation  of  acute  rheumatism,  which  are  now 
practically  abandoned,  are  the  chemical  theory  and  the  nervous  theory.  The 
chemical  theory  assumed  that  acute  rheumatism  was  due  to  the  production, 
within  the  system,  of  lactic  or  uric  acids.  The  lactic  acid  theory  probably 
owed  its  origin  to  the  well-known  sour  smell  and  acid  reaction  of  the 
sweat,  and  the  diminished  alkalinity  of  the  blood,  which  always  accompany 
acute  rheumatism.  It  was  assumed  that,  owing  to  defective  metabolism, 
lactic  acid  or  some  combinations  of  lactic  acid  are  produced,  and  constitute 
the  materies  morbi.  There  is  no  evidence  whatever  in  support  of  this 
view.  As  regards  uric  acid  being  the  causative  factor  of  acute  rheumatism, 
it  is  not  likely  that  that  substance  could  be  the  cause  of  such  diverse 
pathological  conditions  as  those  met  with  in  gout  and  rheumatism.  The 
nervous  theory  regards  the  nerve  centres  as  being  primarily  affected,  and 
regards  the  joint  and  other  troubles  as  being  of  a  trophic  character.  As 
opposed  to  this  view,  no  lesion  of  the  nervous  system  is  associated  with 
acute  rheumatism. 

Morbid  anatomy. — The  pathological  process  in  the  effected  joints 
consists  of  hyperemia,  and  swelling  of  the  synovial  membranes  and  fibrous 
tissues,  with  exudation  of  a  small  amount  of  fluid  into  the  cavity  of  the 
joint.  The  fluid  is  turbid,  albuminous,  and  contains  some  leucocytes  and 
a  few  fibrin  flakes.  A  purulent  effusion  is  very  rare.  Occasionally  there 
may  be  slight  erosion  of  cartilages.  The  fluid  in  the  joints  is  usually 
absorbed  in  a  few  days,  and  acute  rheumatism  rarely  causes  permanent 
injury  of  a  joint.  Lees  and  Poynton  have  shown  that  acute  rheumatism 
may  affect  the  heart  muscle  apart  from   valvular  affection,  a   condition 


474  GENERAL  DISEASES. 

which  is  probably  due  to  the  poison  of  the  disease  producing  a  direct 
effect  upon  the  cardiac  muscle ;  and  Sansom  has  pointed  out  that  valvular 
disease  may  arise  secondarily  as  a  sequela  of  changes  which  were  originally 
myocardial.  The  striking  feature  in  the  cardiac  muscle  fibres  is  the 
extreme  fatty  change.  In  cases  of  hyperpyrexia,  the  blood  usually  contains 
an  excessive  amount  of  fibrin. 

Symptoms. — -Acute  rheumatism. — The  onset  of  acute  rheumatism 
-may  be  abrupt,  but  in  most  cases  is  gradual,  and  is  frequently  preceded  by 
slight  malaise,  by  tonsillitis  (according  to  Fowler,  sore  throat  occurs  in  about 
.80  per  cent,  of  the  cases),  and  by  irregular  pains  in  the  limbs  and  joints. 
The  temperature  rises  quickly,  and  within  twenty-four  hours  from  the  onset, 
the  disease,  as  a  rule,  is  fully  developed.  The  temperature  ranges  from  100° 
to  104°  F.,  and  is  very  irregular,  with  marked  falls  and  rises,  being  highest 
in  the  evening.  The  pulse  is  rapid  and  soft.  The  tongue  is  moist,  covered 
with  a  white  fur,  and  is  often  thickly  coated.  There  is  loss  of  appetite, 
great  thirst,  and  constipation.  Pain  usually  begins  in  one  of  the  larger 
joints — knee,  hip,  elbow,  shoulder,  or  ankle — and  soon  becomes  extremely 
severe.  The  urine  is  scanty,  high  coloured,  and  very  acid.  Profuse  acid 
sweats  occur  over  the  entire  body,  and  the  sweat,  in  the  majority  of  cases, 
possesses  a  peculiar  sour  odour,  which  is  probably  due  to  fermentative 
changes  after  secretion.  Sudamina  are  very  frequently  present  in  abund- 
ance, especially  over  the  chest  and  abdomen.  Except  in  cases  of  hyper- 
pyrexia, the  mind  remains  clear,  and  no  delirium  occurs.  The  joints  are 
swollen,  hot,  and  reddish,  and  are  excessively  painful  to  move.  They  are 
attacked  successively,  and  the  joints  usually  attacked  are  the  knees,  ankles, 
elbows,  wrists,  shoulders,  and  hips.  One  of  the  characteristic  features  of 
the  disease  is  the  migratory  nature  of  the  joint  affection ;  a  joint  which 
one  day  is  swollen  and  painful  may  the  next  day  be  free  from  swelling  and 
pain,  as  the  inflammation  tends  to  subside  in  one  joint,  and  to  develop  in 
another.  The  amount  of  joint  swelling  is  variable,  but  it  is  rare  to  find 
extensive  effusion,  and  much  of  the  enlargement  that  occurs  is  not  due  to 
effusion  into  the  cavity  of  the  joint,  but  to  infiltration  of  the  peri-articular 
tissues  with  serum.  When  the  wrists  and  ankles  are  affected,  it  is  common 
for  the  tendon  sheath  to  be  involved  in  the  swelling,  by  which  means  the 
enlargements  of  the  hands  and  feet  are  considerably  aclded  to.  Amongst 
the  most  distressing  of  the  symptoms  of  the  disease  are  the  agonising  pains 
in  the  joints,  causing  sleeplessness,  the  drenching  sweats,  and  the  extreme 
prostration.  The  duration  of  the  fever  is  variable.  In  young  adults,  if  no 
complications  arise,  the  acute  symptoms  frequently  subside  in  eight  of 
nine  days,  and  convalescence  is  established  in  another  ten  days.  Eelapses, 
however,  are  of  very  common  occurrence.  The  defervescence  of  tempera- 
ture is  usually  gradual,  and  the  remissions  are  frequently  found  to  be 
coincident  with  the  sweats.  The  effect  of  treatment  with  salicylates  is 
generally  to  reduce  the  temperature  to  the  normal  in  from  four  to  five 
days,  or  less. 

Anaemia  is  a  fairly  prominent  symptom  of  rheumatic  fever ;  it  develops 
rapidly,  and  is  associated  with  some  leucocytosis.  The  urine,  as  a  rule,  is 
reduced  in  amount  owing  to  excessive  loss  of  water  by  sweating,  is  of 
high  specific  gravity,  1020-1030,  and  possesses  a  high  colour.  It  has  a 
very  acid  reaction,  and  is  clear  when  first  passed,  but  on  cooling  it  deposits 
an  abundant  quantity  of  amorphous  urates,  and  occasionally  some  crystals 
of  uric  acid.  The  chlorides  of  the  urine  are  generally  diminished  in 
amount,   or   may   be   absent   altogether.      Febrile   albuminuria   not    un- 


ACUTE  RHEUMATISM,  OR  RHEUMATIC  FEVER.        475 

frequently  occurs.  The  heightened  colour  of  the  urine  is  due  to  the 
presence  of  a  large  quantity  of  haematoporphyrin,  and  of  a  small  quantity 
of  urobilin.  The  saliva  may  become  acid,  and  is  said  to  contain  an  excess 
of  sulphocyanides. 

On  account  of  the  great  liability  of  the  heart  to  be  affected  during  an 
attack  of  rheumatic  fever,  it  should  be  examined  each  day  that  the  patient 
is  under  observation ;  and  attention  should  also  be  directed  from  time  to 
time  to  the  lungs.  The  advent  of  pericarditis,  endocarditis,  pleurisy,  or 
pneumonia  is  generally  marked  by  a  rise  of  temperature. 

Subacute  rheumatism. — This  is  a  milder  form  of  the  disease  with 
less  pronounced  symptoms.  The  temperature  rarely  rises  above  101°  F. ; 
fewer  joints  are  involved,  and  the  arthritis  is  less  intense. 

Acute  rheumatism  of  childhood. — In  children  the  non-arthritic 
manifestations  of  rheumatism  are  especially  frequent  and  prominent, 
while  the  articular  manifestations  are  either  slight,  or  may  be  absent 
altogether.  These  points  must  be  carefully  borne  in  mind,  as  otherwise  a 
wrong  diagnosis  may  be  made,  and  irreparable  harm  inflicted  on  a  child 
by  consequent  erroneous  treatment  and  insufficient  rest.  In  early  life 
the  joint  tissues  seem  to  be  much  less  susceptible  to  rheumatic  inflamma- 
tion, whilst  the  non-arthritic  manifestations,  which  are  so  prominent  at 
that  period,  are  the  formation  of  subcutaneous  fibrous  nodules,  erythema, 
purpura  rheumatica,  chorea,  endocarditis,  and  pericarditis.  In  childhood 
the  disease  is  most  common  in  girls,  and,  according  to  Cheadle,  in  70 
per  cent,  of  the  cases  among  children  there  is  a  definite  family  history 
of  rheumatism.  The  profuse  acid  perspirations,  so  marked  in  adults, 
are  not  common  in  children.  Inflammation  of  the  endocardial  covering 
of  the  valves  is  nearly  twice  as  common  among  children  as  among 
adults,  and  it  is  especially  liable  to  come  on  insidiously  in  children. 
It  is  therefore  extremely  important  to  diagnose  minor  attacks  of 
rheumatism  in  children,  as  they  are  frequently  attended  by  a  subacute 
endocarditis  or  pericarditis.  In  connection  with  this  point,  it  should  be 
borne  in  mind  that  the  so-called  "growing  pains,"  of  which  children  so 
frequently  complain,  are,  in  the  great  majority  of  cases,  rheumatic  pains. 
Parents  ought  to  be  impressed  with  the  fact  that  physiological  growth  is 
never  accompanied  by  pain,  and  that  these  erroneously  called  "  growing 
pains  "  are  pathological  in  their  origin,  and  frequently  require  treatment, 
as  otherwise  the  child  may  lapse  into  the  rheumatic  condition. 

Acute  rheumatism  does  not  occur  in  early  infancy.  Cheadle  states 
that  he  has  never  met  with  the  disease  at  that  period  of  life,  a  period  when 
infantile  scurvy  and  syphilitic  affections  of  the  ends  of  the  long  bones 
especially  occur,  and  which  are  apt  to  be  mistaken  for  acute  rheumatism. 

Complications  and  sequelae. — The  complications  and  sequelaa  of 
acute  rheumatism  are  important  and  serious.  It  is  a  question  whether 
the  heart  affections  which  so  frequently  occur  in  connection  with  acute 
rheumatism  should  be  considered  as  complications,  or  rather  as  part  of  the 
disease.  It  is  convenient,  however,  to  include  and  consider  them  in  this 
category.  The  complications  and  sequelae  of  acute  rheumatism  may  be 
arranged  in  seven  groups,  namely,  cardiac  affections,  hyperpyrexia, 
rheumatic  nodules,  pulmonary  affections,  cerebral  complications,  cutaneous 
affections,  and  anaemia. 

Cardiac  affections. — These  consist  of  endocarditis,  pericarditis,  and  myo- 
carditis. Endocarditis  is  the  most  frequent  and  serious  complication  of 
acute  rheumatism.     It  occurs  in  perhaps  over  50  per  cent,  of  cases,  and, 


476  GENERAL  DISEASES. 

according  to  Church,  it  affects  the  sexes  equally.  The  liability  to  endo- 
carditis increases  directly  with  the  number  of  attacks,  rising,  according  to 
Mackenzie,  from  about  58  per  cent,  in  first  attacks  to  about  70  per  cent. 
in  third  attacks ;  but,  on  the  other  hand,  the  liability  to  the  complication 
diminishes  as  age  advances.  The  mitral  segments  are  most  frequently 
affected,  and  the  inflammatory  changes  in  the  valves  lead  to  sclerosis  and 
retraction  of  the  segments,  and  so  to  chronic  valvular  disease.  Ulcerative 
endocarditis  is  of  very  rare  occurrence  in  the  course  of  acute  rheumatism. 
Pericarditis  may  occur  independently  of,  or  together  with,  endocarditis. 
It  is  much  more  frequently  met  with  in  acute  rheumatism  than  as  a 
complication  of  any  other  disease.  According  to  Church,  it  occurs  more 
frequently  among  men  than  women,  and  generally  begins  at  a  much  later 
period  in  the  attack  than  endocarditis  does.  The  risk  of  pericarditis  is 
much  greater  in  first  attacks  than  in  subsequent  ones.  A  peculiar  form  of 
delirium  not  uncommonly  develops  during  the  progress  of  rheumatic 
pericarditis.  Myocarditis  is  most  frequently  noticed  in  connection  with 
combined  endocarditis  and  pericarditis,  and  Church  considers  it  probable 
that  in  all  but  the  slightest  cases  of  pericarditis  a  certain  amount  of 
myocarditis  is  present.  It  is  quite  possible  that  slight  degrees  of 
myocarditis  occur  more  frequently  in  the  course  of  acute  rheumatism  than 
is  generally  suspected.  The  anatomical  condition  is  a  granular  or  fatty 
degeneration  of  the  cardiac  muscle,  which  leads  to  weakening  of  the  walls 
and  to  dilatation. 

Hyperpyrexia. — This  is  a  very  serious  complication.  The  temperature 
may  rise  rapidly  a  few  days  after  the  commencement  of  the  attack  of  acute 
rheumatism,  and,  with  the  rise  of  temperature,  the  pain  in  the  joints 
lessens,  the  profuse  sweating  diminishes,  and  the  patient  becomes  at  first 
extremely  restless ;  later  on,  the  hyperpyrexia  may  be  associated,  though 
not  necessarily,  with  delirium.  This  complication  is  more  common  in 
first  attacks  of  acute  rheumatism,  and  especially  occurs  during  the  second 
week  of  the  attack.  The  temperature  rises  from  105°  to  111°  F.  The 
pulse  is  feeble  and  frequent,  the  patient  becomes  extremely  prostrated,  and 
if  death  is  about  to  occur,  a  condition  of  stupor  comes  on,  passing  into  coma. 

Rheumatic  nodules. — These  consist  of  small  subcutaneous  fibrous 
nodules  attached  to  the  tendons  and  fasciae.  They  vary  in  size  from  a 
small  shot  to  a  large  pea,  and  are  most  numerous  on  the  fingers,  hands, 
and  wrists,  but  also  occur  about  the  elbows,  knees,  spines  of  the  vertebra?, 
and  the  scapula?.  In  children  they  are  most  commonly  found  upon  the 
backs  of  the  elbows,  over  the  malleoli,  and  at  the  margins  of  the  patella?. 
As  a  rule,  they  are  not  tender.  They  frequently  develop  with  great 
rapidity,  and  usually  last  for  weeks  or  months.  They  are  more  common 
in  children  than  adults,  and  are  particularly  associated  with  severe 
endocarditis.  Cheadle  considers  that  the  eruption  of  large  nodules 
signifies  persistent  and  uncontrollable  cardiac  disease,  which  almost 
invariably  terminates  fatally.  Histologically,  the  nodules  present  a 
structure  similar  to,  if  not  identical  with,  that  found  in  the  nodular 
growths  on  the  cardiac  valves. 

Pulmonary  affections. — Pneumonia  and  pleurisy  are  occasional  com- 
plications of  acute  rheumatism,  especially  in  connection  with  endocarditis 
and  pericarditis.     Congestion  of  the  lungs  occasionally  occurs. 

Cerebral  complications. — Chorea  is  apt  to  develop  in  connection  with 
slight  attacks  in  childhood.  Delirium  is  usually  associated  with  hyper- 
pyrexia, but  also  may  be  excited  by  the  over-administration  of  sodium 


A  C  UTE  RHE  UMA  TISM,  OK  RHE  UMA  TIC  FE  VER.        4  7  7 

salicylate,  or  the  employment  of  the  drug  in  an  impure  state ;  it  is 
generally  of  the  active  and  noisy  kind,  but  frequently,  in  cases  of 
hyperpyrexia,  passes  into  the  low,  muttering  variety,  followed  by  stupor 
and  coma.  Coma,  which  is  a  serious  symptom,  may  occasionally  develop 
without  preliminary  delirium,  and  sometimes  independently  of  hyper- 
pyrexia. Convulsions  only  occur  on  rare  occasions,  but  they  may  precede 
the  advent  of  coma.     Meningitis  is  an  extremely  rare  complication. 

Cutaneous  affections. — As  previously  mentioned,  sudamina  are  extremely 
common  in  acute  rheumatism.  A  red  miliary  rash  may  develop,  and 
scarlatiniform  eruptions  very  occasionally  occur.  Purpura,  urticaria,  and 
various  forms  of  erythema  are  not  uncommonly  met  with. 

Anosmia. — This  is  rather  a  constant  accompaniment  of  rheumatic 
fever  than  a  complication.  Hayem  and  Garrod  have  shown  that  a 
considerable  fall  in  the  number  of  red  corpuscles  and  some  slight 
leucocytosis  accompany  an  attack  of  acute  rheumatism. 

Diagnosis  and  prognosis. — The  differential  diagnosis  of  rheu- 
matism, gout,  and  rheumatoid  arthritis  is  dealt  with  in  a  subsequent  article 
(see  pp.  485-487).  In  addition  to  gout  and  rheumatoid  arthritis,  pyaemia, 
secondary  to  bone  disease,  may  be  mistaken  for  acute  rheumatism.  The 
occurrence  of  rigors,  the  detection  of  bone  disease,  the  non-migratory 
nature  of  the  joint  affections,  and  the  absence  of  profuse  sweats,  tend  to 
distinguish  pyaemia  from  acute  rheumatism. 

The  course  of  acute  rheumatism  is  extremely  variable.  The  mortality 
during  an  acute  attack  is  very  small,  and  is  then  nearly  always  due  to 
hyperpyrexia,  or  to  some  secondary  lesion,  such  as  pericarditis  or 
endocarditis,  or,  more  rarely,  pneumonia  or  pleurisy.  Sudden  death  in 
rheumatic  fever,  though  a  very  exceptional  occurrence,  is  most  frequently 
due  to  myocarditis  ;  more  rarely  it  results  from  embolism.  The  prognosis 
in  acute  rheumatism  is  far  more  serious  in  the  case  of  children  than  in 
that  of  adults,  mainly  owing  to  the  greater  liability  among  children  to 
endocarditis  and  pericarditis. 

Treatment. — A  patient  suffering  from  acute  rheumatism  should  wear 
a  woollen  night-gown,  which  should  be  frequently  changed  if  much 
sweating  occurs.  The  bed  should  be  flat  and  smooth,  and  the  patient 
should  lie  on  blankets,  and  be  lightly  covered  with  blankets  only.  No 
sheets  should  be  used,  on  account  of  the  liability  to  chill  when  they 
become  soaked  with  perspiration.  Absolute  and  prolonged  rest  is  a  most 
essential  factor  in  the  treatment  of  acute  rheumatism.  The  diet  during 
the  acute  stage  should  consist  mainly  of  milk,  to  which  some  common  salt 
may  be  added  with  advantage.  Ewart  recommends  the  addition  of  15  grs. 
of  salt  to  each  half-pint  of  milk.  In  addition,  good  soups,  especially 
made  with  vegetables,  and  animal  broths  in  moderate  quantities,  may  be 
given.  Lemonade,  barley  water,  infusion  of  tamarinds,  or  imperial  drink, 
should  be  freely  given  to  allay  the  thirst.  As  convalescence  is  established, 
the  patient  may  be  put  on  a  fuller  and  more  liberal  diet. 

With  regard  to  drug  treatment,  there  are  two  methods  which  are 
specially  employed,  one  is  the  treatment  with  salicyl  compounds,  and  the 
other  the  alkaline  treatment.  Maclagan  considers  that  the  salicyl  com- 
pounds exert  a  specific  and  curative  action  on  the  disease.  Certainly,  if 
administered  in  sufficient  quantities,  they  rapidly  relieve  the  pain  and 
reduce  the  temperature.  The  alkaline  treatment,  which  was  first  advocated 
by  Fuller,  was  based  on  the  theory  that  rheumatism  was  due  to  the 
presence  of  an  acid  in  the  blood.     It  is  the  opinion  of  many  observers  that 


478  GENERAL  DISEASES. 

heart  complications  are  less  frequent  among  those  patients  who  have  been 
treated  with  alkalies,  and  this  has  been  ascribed  to  the  influence  of  the 
alkalies  in  preventing  the  coagulation  of  fibrin.  In  the  experience  of  the 
writer,  acute  rheumatism  is  most  successfully  treated  by  a  combination  of 
a  salicyl  compound  with  an  alkali.  For  an  adult,  20  grs.  of  sodium 
salicylate  and  30  grs.  of  potassium  bicarbonate  should  be  given  every  two 
hours,  until  the  pain  is  relieved  and  the  patient  is  fully  under  the  influence 
of  the  salicylate,  when  the  same  quantities  should  be  given  every  four 
hours  till  the  temperature  has  fallen  to  normal.  Afterwards,  15  grs.  of 
salicylate  and  20  grs.  of  the  bicarbonate  should  be  given  every  four  hours 
for  about  a  fortnight.  If  the  salicylate  is  pushed  too  far,  it  produces 
deafness,  noises  in  the  ears  and  head,  and  delirium,  which  are  indications 
for  the  reduction  in  the  dose,  or  even  possibly  for  its  withdrawal.  These 
effects  are  to  a  great  extent  obviated  by  producing  a  free  action  of  the 
bowels  at  the  outset  by  means  of  a  dose  of  calomel,  followed  by  a  saline 
purge,  such  as  magnesium  sulphate  or  sodium  sulphate.  Moreover,  the 
sodium  salt  of  the  natural  salicylic  acid  should  be  employed,  as  the 
artificially  prepared  salicylic  acid  is  much  more  liable  to  produce  toxic 
effects,  probably  on  account  of  the  presence  of  paracresotic  acid  in  it. 
If  by  any  chance  the  sodium  salicylate  is  not  well  tolerated,  an  equal 
quantity  of  salicin  should  be  substituted  for  it,  and  given  in  combination 
with  the  bicarbonate.  Maclagan  prefers  the  use  of  salicin  as  not  being  a 
depressant  to  the  nervous  system,  and  advocates  the  use  of  20  to  30  grs. 
every  hour  till  the  fever  and  acute  symptoms  disappear.  The  heart  should 
be  carefully  examined  each  day  during  the  administration  of  the  salicylate 
and  alkali,  as  they  tend  to  exert  a  depressing  effect  on  it.  If  pericarditis 
or  endocarditis  supervenes,  it  is  advisable  to  discontinue  the  use  of  the 
salicylate,  and  to  substitute  salicin  for  it.  Sodium  salicylate  should  not 
be  given  in  the  acute  rheumatism  of  children.  For  children,  salicin  and 
alkalies  should  be  employed.  For  the  relief  of  the  pain  in  the  joints, 
tincture  of  iodine  may  be  painted  over  each  affected  joint,  which  should 
then  be  completely  enveloped  in  a  hot  linseed  poultice,  and  surrounded 
with  plenty  of  cotton-wool  and  a  flannel  bandage;  the  entire  dressing 
should  then  be  left  untouched  for  twenty-four  hours.  Another  method 
of  considerably  relieving  the  pain  and  inflammation  of  the  joints  is  by  the 
application  of  salicylate  of  methyl.  A  piece  of  lint  saturated  with  about 
a  teaspoonful  of  salicylate  of  methyl  is  placed  over  the  affected  joint,  and 
upon  this  a  piece  of  guttapercha  tissue,  overlapping  the  lint  by  about  an 
inch  all  round,  is  laid ;  the  edges  of  the  under  portion  of  the  guttapercha 
tissue  are  then  sealed  down  to  the  skin  by  wetting  with  a  little  chloroform, 
after  which  some  wool  and  a  bandage  are  applied.  At  the  end  of  twenty- 
four  hours  the  salicylate  of  methyl  will  be  found  to  have  undergone 
complete  absorption.  The  only  drawback  to  this  method  of  treatment  is 
the  peculiar  penetrating  odour  of  the  salicylate  of  methyl.  The  pain  in 
the  joints  may  also  be  relieved  by  the  application  of  chloroform  liniment, 
or  by  applying  blisters  above  and  below  the  joints,  or  by  the  light 
application  of  the  Paquelin  thermo-cautery. 

For  the  general  relief  of  pain,  it  is  occasionally  advisable  to  administer 
opium  in  the  form  of  Dover's  powder,  and  phenacetin,  antifebrin,  and  anti- 
pyrine  are  sometimes  useful  for  the  same  purpose,  but  these  drugs  exercise 
no  beneficial  action  on  the  disease.  If  cardiac  failure  and  prostration 
occur,  moderate  quantities  of  brandy  (2  to  3  oz.  in  the  twenty-four  hours) 
may   be   given,   but  in  cases  complicated  with  severe  endocarditis,  peri- 


CHRONIC  RHE  UMA  TISM.  479 

carditis,  or  myocarditis,  stimulants  must  be  given  more  freely.  For  the 
prevention  of  cardiac  complications,  Caton  applies  small  blisters  (about 
the  size  of  a  florin)  between  the  clavicle  and  the  nipple,  over  the  first, 
second,  third,  and  fourth  dorsal  nerves,  either  on  the  right  or  the  left  side. 
They  are  applied  one  at  a  time,  and  repeated  at  different  points.  These 
nerves  are  possibly  in  close  association  with  the  heart,  and  the  treatment, 
which  is  strongly  advocated  by  Caton,  is  very  successful.  During  con- 
valescence the  cinchona  preparations  or  quinine  should  be  given.  Iron 
is  frequently  not  well  borne,  but  it  should  be  cautiously  tried  on  account 
of  the  anaemia.  It  is  best  administered  in  the  form  of  the  scale  com- 
pounds or  of  Blaud's  pills.  Patients  should  be  kept  in  bed  for  about  six 
weeks,  in  order  to  prevent  the  liability  to  relapses  and  to  cardiac  com- 
plications. 

Hyperpyrexia  requires  prompt  and  energetic  treatment.  It  is  best 
treated  by  immersion  of  the  patient  in  a  cold  bath  at  a  temperature  of 
65°  F.;  and  as  the  temperature  of  the  water  is  raised  by  the  immersion 
of  the  patient,  ice  should  be  added.  If  facilities  for  the  cold  bath  are  not 
at  hand,  then  the  ice-pack,  or  the  rubbing  of  the  body  with  lumps  of  ice, 
will  prove  very  effective.  In  either  case,  the  head  should  be  sponged  with 
ice-cold  water,  or  an  ice-bag  should  be  applied.  If  possible,  the  patient 
should  be  kept  in  the  bath  till  the  temperature  has  fallen  6°,  but  if 
shivering  occurs  the  patient  must  be  removed  at  once  from  the  bath  or 
pack.  The  bath  may  have  to  be  repeated  several  times,  and  stimulants 
should  be  given  to  combat  any  collapse.  Endocarditis  and  pericarditis 
must  be  suitably  treated,  as  described  in  connection  with  those  diseases. 

A.  P.  LUFF. 


CHEONIC  BHEUMATISM. 


Many  cases  supposed  to  be  chronic  rheumatism  are  cases  of  chronic 
rheumatoid  arthritis  or  of  chronic  articular  gout.  Most  frequently  the 
affection  takes  the  form  of  slight  recurrent  articular  attacks,  especially  in 
those  with  a  family  history  of  rheumatism.  The  articular  attacks  may 
come  on  insidiously,  and  especially  occur  in  persons  past  middle  life. 
Another  class  of  cases,  those  of  chronic  abarticular  rheumatism,  are  most 
frequently  met  with  in  children,  and  in  early  adult  life.  These  cases 
consist  of  such  rheumatic  manifestations  as  subcutaneous  fibrous  nodules, 
erythema,  and  chorea,  which  have  been  previously  referred  to.  A  chronic 
form  of  rheumatism  affecting  the  finger-joints  is  that  known  as  rhumatisme 
fibreux,  in  which  the  finger-joints  present  fusiform  enlargements,  due  to 
thickening  of  the  joint  capsules. 

Morbid  anatomy. — The  synovial  membranes  are  injected,  but 
usually  there  is  not  much  effusion  into  the  cavities  of  the  joints.  Inter- 
ference with  the  movements  of  the  joints  results  from  thickening  of  the 
capsules,  ligaments,  and  tendon  sheaths  in  the  neighbourhood  of  the  joints, 
and  from  a  certain  degree  of  atrophy  of  the  muscles. 

Symptoms. — There  is  stiffness  of  the  affected  joints,  and  pain,  wdiich 
varies  with  changes  in  the  weather,  and  which  is  more  marked  after  rest. 
The  joints  are  tender  and  a  little  swollen,  and  the  joint  affection  usually 
shows  the  same  tendency  to  shift  from  joint  to  joint  as  in  the  acute  disease. 
Creaking  in  the  affected  joints  is  very  common,  and  ankylosis  may  occur 


4So  GENERAL  DISEASES. 

in  those  cases  which  are  sequels  of  acute  rheumatism.     The  temperature  is 
seldom  raised. 

Prognosis  and  treatment. — Chronic  rheumatism  is  obstinate  as 
regards  treatment,  and  the  affection,  when  once  settled  in  a  joint,  may 
persist  indefinitely,  but  does  not  necessarily  shorten  life.  Attacks  of 
articular  pain  usually  yield  rapidly  to  treatment  with  sodram  salicylate, 
but  in  the  more  chronic  cases  the  salicyl  preparations  may  be  useless. 
Iodide  of  potassium  and  guaiacum  are  sometimes  very  beneficial ;  the 
iodide  should  be  given  in  doses  of  5  to  15  grs.  in  a  mixture,  and  the 
guaiacum  resin  in  doses  of  5  to  10  grs.  in  cachets.  Quinine  and  alkalies 
are  also  frequently  useful.  Local  treatment,  in  the  form  of  counter- 
irritation  and  massage,  is  often  of  great  benefit.  Useful  adjuncts  in  the 
treatment  of  chronic  rheumatism  are  radiant  heat  baths,  superheated  air 
baths,  electric  baths,  brine  baths  as  at  Droitwich,  peat  baths  as  at 
Strathpeffer,  hot  alkaline  baths,  and  douche  massage.  Cold  and  damp 
weather  should  be  avoided. 

Muscular  Eheumatism. 

This  is  a  term  applied  to  a  myalgia  resulting  from  exposure  to  cold 
and  damp,  or  from  muscular  overstrain.  Probably  the  affection  has  no 
direct  relationship  to  acute  rheumatism.  Various  views  have  been  ad- 
vanced to  explain  the  causation  of  the  muscular  pain,  such  as  active 
hyperemia,  or  a  neuralgic  affection  of  the  terminations  of  the  nerves  in 
muscles,  or  slight  inflammatory  changes  in  the  fibrous  tissues  of  the 
muscles. 

Etiology. — Muscular  rheumatism  is  most  commonly  met  with  in 
men,  particularly  among  those  exposed  to  cold,  and  to  sudden  alterations  of 
temperature.  Persons  of  a  rheumatic  or  gouty  habit  are  especially  prone 
to  the  affection. 

Symptoms. — Pain,  especially  when  the  affected  muscles  are  used  or 
put  upon  the  stretch,  is  the  most  prominent  symptom,  while  tenderness  on 
pressure  of  the  affected  muscles  is  also  an  important  diagnostic  sign ; 
the  affected  muscles  are  frequently  spasmodically  contracted,  as  in 
cases  of  stiff  neck  or  rheumatic  torticollis,  in  which  the  sterno-mastoid 
is  the  seat  of  the  affection.  In  very  acute  cases,  especially  in  cases 
of  the  variety  known  as  "lumbago,"  the  pain  comes  on  with  extreme 
suddenness,  frequently  giving  the  impression  that  a  muscle  has  been  over- 
strained, but  in  chronic  cases  the  onset  is  gradual  and  insidious.  In  acute 
cases  the  pain  usually  lasts  only  a  few  days,  but  in  chronic  cases  it  may 
persist  for  months  or  longer. 

The  forms  of  muscular  rheumatism  may  be  classified  according  to  the 
groups  of  muscles  involved.     These  are — 

Lumbago. — This  form  is  almost  entirely  met  with  in  adult  life.  It 
affects  the  muscles  of  the  loins  and  their  tendinous  attachments.  The 
pain  is  greatly  increased  by  movement,  and  especially  by  stooping  and 
then  resuming  the  erect  posture.  The  patient  may  be  quite  unable  to 
turn  in  bed,  or  to  rise  from  the  sitting  position. 

Intercostal  rheumatism,  or  pleurodynia. — This  affection  of  the 
intercostal  muscles  is  diagnosed  by  the  absence  of  the  signs  of  pleurisy 
and  of  herpes  zoster,  and  by  the  pain  elicited  on  pressure  over  the  affected 
muscles.     A  deep  breath  or  coughing  also  causes  intense  pain. 

Rheumatic  torticollis,  or  stiff  neck. — This  form  especially  occurs  in 


RHEUMATOID  ARTHRITIS.  481 

childhood.  One  or  both  sterno-mastoids  may  be  affected,  but  usually  the 
attack  is  confined  to  one  side.  The  affection  is  accompanied  by  muscular 
spasm,  and  the  patient  in  attempting  to  turn  the  head  rotates  the  whole 
body. 

Treatment. — Eest  of  the  affected  muscles  is  most  important;  in 
cases  of  intercostal  rheumatism,  strapping  the  side  gives  great  relief  by 
insuring  the  necessary  rest.  Sodium  salicylate  is  most  useful  for  the  relief 
of  the  pain,  especially  in  acute  cases,  and  it  may  be  usefully  combined  with 
full  doses  of  nux  vomica.  In  chronic  cases,  alkalies,  in  conjunction  with 
potassium  iodide  and  guaiacum  resin  in  cachets,  should  be  given.  In  very 
acute  cases  it  may  be  necessary  to  give  a  local  subcutaneous  injection  of 
morphine  for  the  relief  of  the  pain.  For  acute  cases  of  lumbago,  acu- 
puncture is  very  effective;  needles  of  about  4  in.  in  length  are  thrust 
into  the  affected  muscles,  and  withdrawn  after  five  to  ten  minutes.  A 
very  useful  method  of  treating  many  forms  of  muscular  rheumatism  is  to 
have  an  embrocation,  consisting  of  equal  parts  of  the  compound  camphor 
liniment  and  of  soap  liniment,  well  rubbed  over  the  affected  area,  and  then 
to  have  the  part  ironed  with  a  hot  iron  through  a  sheet  of  brown  paper 
spread  over  the  skin,  the  iron  being  as  hot  as  can  be  borne  by  the  patient. 
Muscular  rheumatism  is  also  successfully  treated  by  radiant  heat  baths, 
superheated  air  baths,  electric  baths,  ordinary  hot  baths,  brine  baths,  and 
peat  baths. 

A.  P.  LUFF. 


EHEUMATOID  AETHEITIS. 


This  is  a  progressive  degeneration  of  the  joints,  consisting  of  changes  in 
the  synovial  membranes,  cartilages,  and  bones,  accompanied  by  atrophy 
of  some  structures  and  by  hypertrophy  of  others.  In  chronic  cases, 
marked  osteophytic  outgrowths  are  peculiar  to  this  disease.  Eheumatoid 
arthritis,  which  is  a  distinct  disease  from  gout  and  rheumatism,  has 
frequently  been  mistaken  for  one  or  other  of  these  diseases,  and  the 
confusion  has  doubtless  been  intensified  by  the  ambiguity  of  the  terms 
used  to  describe  the  disease.  Eheumatoid  arthritis  is  known  under  the 
various  names  of  "  osteo-arthritis,"  "  rheumatic  gout,"  "  arthritis  deformans," 
"polyarthritis  deformans,"  chronic  rheumatic  arthritis,"  "pernicious 
arthritis,"  and  " rhumatisme  chroniqiie  infectieux."  In  Germany  and  America 
it  is  generally  known  as  "arthritis  deformans."  Heberden  was  one 
of  the  first  to  distinguish  between  this  disease  and  rheumatism. 
He  pointed  out  that  there  was  swelling  of  the  affected  joint,  but  little 
or  no  fever,  no  great  pain,  and  no  redness  of  the  skin ;  that  the  disease 
generally  attacked  joint  after  joint,  and  that  it  was  very  crippling ;  that 
the  fingers  and  wrists  were  especially  liable  to  the  disease,  and  that  the 
terminal  phalangeal  joints  of  the  fingers  were  liable  to  become  affected 
with  nodosities,  which  have  since  become  known  as  "  Heberden's  nodes." 

Etiology. — Eheumatoid. arthritis,  in  its  rarer  and  acute  form,  occurs 
especially  in  children  and  young  adults,  whereas  in  its  commoner  and. 
chronic  form  it  is  most  frequently  seen  at  and  after  middle  life.  In  its 
chronic  form  it  is  much  more  common  amongst  women  than  men,  probably 
on  account  of  the  liability  of  women  to  affections  of  the  genito-urinary 
tract,  to  excessive  child-bearing,  and  from  prolonged  lactation.  Direct 
inheritance  of  rheumatoid  arthritis  cannot  be  clearly  traced,  as  in  the 

VOL.  I. — 31 


48 2  GENERAL  DISEASES. 

cases  of  gout  and  rheumatism,  but  in  those  inheriting  a  tendency  to  joint 
troubles  one  member  of  a  family  may  develop  gout,  another  rheumatism, 
and  another  rheumatoid  arthritis.  Rheumatoid  arthritis  almost  entirely 
occurs  in  debilitated  subjects,  and  is  therefore  a  frequent  sequela  of  any 
condition  which  has  impaired  the  nutritional  state  of  the  body  generally. 
Injury  to  a  joint,  using  the  term  injury  in  its  widest  sense,  such  as  that 
caused  by  rheumatism,  gout,  gonorrhoea,  septic  troubles,  etc.,  predisposes 
to  this  disease.  Rheumatoid  arthritis  is  common  amongst  the  poor  and 
ill-nOurished.  For  its  successful  treatment  an  abundant  and  generous 
diet  is  required.  Cold  and  damp  soils  and  sudden  alterations  of  tempera- 
ture are  favourable  to  the  development  of  the  disease. 

Morbid  anatomy. — The  disease  of  the  joints  involves  cartilage, 
bone,  and  synovial  membrane.  The  synovial  membrane  is  usually  the 
first  part  of  the  joint  to  become  affected.  The  articular  ends  of  the  bones 
become  thickened,  and  present  projecting  osteophytic  growths.  The 
inflammatory  process  causes  denudation  of  the  cartilage,  which  ultimately 
leads  to  exposure  of  the  surface  of  the  bone.  The  exposed  surfaces  of  the 
bones  then  become  eburnated  by  mutual  friction,  the  eburnated  portions 
being  hard  and  polished.  The  synovial  membrane  is  generally  thickened, 
and  the  amount  of  synovial  fluid  is  increased.  The  capsules  of  the  joints 
become  thickened,  and  may  be  the  seat  of  ossification.  In  the  early  stages 
of  the  disease  the  spindle-shaped  swellings  of  the  affected  joints  are  mainly 
due  to  thickening  of  the  synovial  membranes,  and  of  the  capsules  of  the  joints, 
and  only  to  a  very  slight  degree  to  osteophytic  outgrowths.  The  nodular 
protuberances,  so  suggestive  of  the  disease  in  its  later  stages,  are  in  part  due 
to  ossification  of  the  hypertrophied  cartilages  at  the  periphery,  and  in  part 
to  osteophytic  outgrowths  from  the  bone.  These  osteophytic  outgrowths 
may  lead  to  complete  locking  of  the  joints.  The  ligaments  of  the  joints 
are  usually  considerably  thickened,  and  so  assist  in  the  locking  of  the 
joints.  The  heads  of  the  bones  may  undergo  either  hypertrophy  or 
atrophy.  No  deposits  of  sodium  biurate  occur  in  the  joints  as  in  gout, 
and  the  disease  differs  from  chronic  rheumatism  in  the  existence  of 
extensive  structural  alterations.  Bursal  swellings  are  occasionally  met 
with  in  the  vicinity  of  the  affected  joints.  The  fingers  are  frequently 
"deflected  to  the  ulnar  side,  a  deformity  which  is  probably  due  to  disease  of 
the  metacarpo-phalangeal  joints,  and  the  toes  may  show  a  similar  deflection. 
Spasm  of  the  atrophied  muscles  may  cause  various  deformities,  such  as 
flexion  of  the  limbs  at  the  knees,  elbows,  and  wrists,  and  flexion  of  the 
metacarpo-phalangeal  joints,  with  hyper-extension  of  the  first  interphal- 
angeal  and  compensatory  flexion  of  the  terminal  phalangeal  joints. 

Pathology. — At  the  present  time  two  views  are  held  by  different 
observers  as  to  the  origin  of  rheumatoid  arthritis.  One  view  attributes  it 
to  a  nervous  cause,  while  the  other  regards  it  as  an  infective  disease  due  to 
micro-organisms  settling  in  the  joints.  Those  who  favour  the  nervous 
view  argue  that  the  changes  in  the  joints  are  similar  to  those  met  with  in 
the  chronic  spinal  arthropathies,  such  as  are  met  with  in  locomotor  ataxy, 
syringomyelia,  and  hemiplegia,  and  that  the  muscular  atrophy  and  the 
dystrophies  of  the  nails  and  skin  that  are  frequently  associated  with 
rheumatoid  arthritis  are  of  neurotic  origin.  Moreover,  it  is  stated  that  the 
symmetrical  progress  of  the  disease  which  is  so  often  seen,  and  the 
occasional  indications  of  neuritis  during  life,  and  of  its  very  occasional 
discovery  post-mortem,  support  the  view  as  to  the  nervous  origin  of  the 
disease.     Senator  regarded  the  facts  that  the  muscular  wasting  may  be  out 


RHEUMATOID  ARTHRITIS.  483 

of  proportion  to  the  joint  mischief,  and  that  the  disease  may  be  started  by 
violent  emotion  and  grief,  as  evidences  of  the  origin  of  the  disease  from  a 
central  nervous  cause.  On  the  other  hand,  those  who  favour  the  view  that 
rheumatoid  arthritis  is  an  infective  disease,  find  support  in  the  facts — (1) 
that  it  frequently  occurs  as  a  sequela  to  some  acute  infection,  such  as 
acute  rheumatism,  influenza,  gonorrhoea,  scarlet  fever,  and  tonsillitis;  (2) 
that  its  acute  mode  of  onset  in  certain  cases  is  suggestive  of  an  acute 
infective  process ;  (3)  that  the  rheumatoid  arthritis  of  children  is  associated 
with  widespread  enlargement  of  lymphatic  glands  and  swelling  of  the 
spleen ;  and  (4)  that  in  a  certain  number  of  cases,  micro-organisms  have 
been  discovered  in  the  fluid  of  the  joints.  Bannatyne  and  Wohlmann  have 
isolated  a  short,  dumb-bell-shaped  bacillus  from  the  synovial  fluid,  synovial 
membranes,  cartilages,  and  the  bony  debris  of  erosions  of  affected  joints  in 
cases  of  rheumatoid  arthritis.  In  a  few  instances  they  have  also  isolated 
the  same  bacillus  from  the  blood.  The  organism  was  not  found  in  the 
fluid  of  the  joints  in  other  cases  of  synovitis.  The  observations  of 
Bannatyne  and  Wohlmann  have  been  confirmed  by  Blaxall.  Recently, 
von  Dungern  and  Schneider  made  cultivations  of  the  organism  from  a 
case  of  rheumatoid  arthritis,  which  after  many  years  ended  fatally,  and  on 
injecting  cultures  into  the  joints  of  rabbits  they  state  that  a  similar 
articular  disease  was  produced  to  that  from  which  the  patient  had  suffered. 

With  regard  to  these  two  views,  it  is,  in  the  first  place,  probable  that 
under  the  name  of  rheumatoid  arthritis  more  than  one  distinct  disease  is 
included,  and  it  is  possible  that  the  acute  and  chronic  forms  may  be  dis- 
tinct diseases,  and  due  to  entirely  different  causes.  The  balance  of  evidence 
seems  to  be  in  favour  of  acute  rheumatoid  arthritis  being  an  infective 
disease,  and  that  it  is  due  to  a  settlement  of  micro-organisms  in  the 
affected  joints,  that  there  they  produce  a  toxine,  and  that  that  toxine,  passing 
into  the  circulation,  is  responsible  for  any  nervous  symptoms  which  occur  in 
the  disease.  Certainly  the  tachycardia,  local  sweatings,  and  pigmentation 
which  frequently  accompany  rheumatoid  arthritis,  are  readily  explicable  if 
absorption  of  certain  toxines  into  the  general  circulation  occurs,  without 
requiring  the  agency  of  the  nervous  system  to  account  for  them. 

The  usually  symmetrical  nature  of  the  affection  first  gave  support  to 
the  view  that  the  disease  was  nervous  in  its  origin,  but,  as  opposed  to  this, 
it  must  be  borne  in  mind  that  it  does  not  begin  in  a  symmetrical  way. 
It  generally  begins  in  one  joint  on  one  side,  and  then  spreads.  Another 
reason  for  supposing  the  disease  to  be  of  nervous  origin  is  on  account  of 
the  muscular  atrophy  which  takes  place  when  the  larger  joints  are  affected. 
This  muscular  wasting,  however,  goes  on  in  every  form  of  chronic  arthritis 
in  which  there  is  much  disuse  of  muscles.  If  this  wasting  were  due  to 
any  central  nervous  affection,  there  would  be  present  in  the  affected 
muscles  the  reaction  of  degeneration,  which,  however,  is  never  obtainable 
in  rheumatoid  arthritis.  Perhaps  the  most  serious  objection  to  the  nervous 
hypothesis  is,  that  no  central  nerve  lesion  has  ever  been  discovered. 
Careful  examinations  have  been  made  of  the  spinal  cord  in  cases  of 
rheumatoid  arthritis,  but  no  lesions  or  degenerations  have  been  found. 

Symptoms. — The  disease  occurs  in  acute,  subacute,  and  chronic 
forms.  The  acute  and  subacute  forms  are  characterised  by  inflammatory 
changes  in  the  affected  joints,  by  erosion  of  cartilages  and  bones,  by  nerve 
and  trophic  phenomena,  and  by  glandular  enlargement.  It  is  polyarticular, 
and  in  its  acute  and  subacute  forms  occurs  especially  in  children  and  young 
adults.     The  disease  usually  commences  in  one  joint,  commonly  one  of  the 


484  GENERAL  DISEASES. 

metacarpophalangeal  articulations,  and  then  rapidly  spreads  to  most  of 
the  other  joints.  The  symmetrical  nature  of  the  affection  is  usually  well 
marked,  and  the  joints  are  painful,  hot,  and  present  a  spindle-shaped 
enlargement,  but  no  outgrowth  or  thickening  of  either  cartilage  or  bone. 
The  chronic  forms  are  characterised  by  progressive  thickening  and  harden- 
ing of  all  the  joint  structures,  by  the  formation  of  osteophytes,  by  the 
lipping  of  cartilages,  and  by  the  development  of  deformities.  The  disease 
in  its  chronic  form  may  be  the  later  stages  of  an  acute  attack,  or  may  be 
chronic  from  the  outset.  It  may  affect  several  joints,  or  be  confined  to 
one  or  two. 

As  a  rule,  rheumatoid  arthritis  commences  insidiously.  It  usually 
begins  with  pain,  not  necessarily  severe,  in  the  affected  joint  or  joints, 
which  is  especially  apt  to  occur  after  an  exposure  to  chill,  or  after  some 
depressing  condition.  Pain  in  the  ball  of  the  thumb  is  very  suggestive  of 
the  commencement  of  rheumatoid  arthritis.  The  swelling  of  the  joint  is 
slow,  and  grating  on  rubbing  the  ends  of  the  bones  against  each  other  is. 
only  obtained  later  in  the  course  of  the  disease. 

The  three  divisions  of  the  disease  proposed  by  Charcot  constitute  the 
best  classification  of  the  forms  of  rheumatoid  arthritis  for  a  study  of  their 
symptoms.  They  are — cases  with  Heberden's  nodes,  the  general  pro- 
gressive form,  and  the  partial  or  monarticular  form. 

Cases  with  Heberden's  nodes. — These  cases  represent  the  mildest 
degree  of  the  disease.  The  nodes  consist  of  little  hard  swellings  of  the 
finger  joints,  especially  of  the  terminal  phalanges,  and  are  due  to  a  very 
chronic  form  of  rheumatoid  arthritis.  This  type  is  more  commonly  met 
with  in  women  than  in  men,  and  usually  at  or  after  the  middle  period  of 
life.  The  nodules  are  due  to  enlargement  of  the  ends  of  the  bones,  which 
are  frequently  covered  by  a  pouch  of  the  projecting  synovial  membrane, 
which  acts  somewhat  as  a  bursa.  The  joints  become  swollen  and  tender, 
the  cartilages  are  softened,  and  the  ends  of  the  bones  are  eburnated.  After 
a  time  the  disease  usually  becomes  arrested,  but  the  swellings  remain,  and 
eventually  may  cause  no  discomfort.  Osier  states  that  the  subjects  of  these 
nodules  rarely  suffer  in  the  larger  joints. 

The  general  progressive  form. — Of  this  there  are  two  varieties — 
the  acute  and  chronic.  The  acute  form  has  been  previously  referred 
to.  It  may  resemble,  and  certainly  has  been  mistaken  for,  acute 
articular  rheumatism.  It  generally  starts  in  one  joint,  and  subsequently 
involves  many.  There  is  not  much  redness  of  the  affected  joints,  and  only 
moderate  fever.  It  is  most  common  in  children,  young  adults,  and  young 
women.  Among  the  last-mentioned  it  is  often  connected  with  recent 
delivery,  rapid  child-bearing,  or  excessive  lactation.  The  chronic  form  is 
much  commoner  than  the  acute.  The  joints  that  have  been  most  especi- 
ally and  actively  used,  according  to  the  former  occupation  or  employment 
of  the  patient,  are  those  which  usually  show  the  first  signs  of  the  disease. 
The  affection  commences  with  slight  swelling  and  pain  on  movement. 
The  amount  of  effusion  into  the  joint  is  variable,  and  may  be  marked  or 
slight.  The  hands  and  feet,  especially  the  hands,  are  most  liable  to  be 
first  affected,  and  the  disease  then  tends  to  advance  more  or  less  up  the 
limbs  towards  the  trunk,  obeying,  as  Charcot  described,  "  the  centripetal 
law."  In  extreme  cases  every  joint  in  the  body  may  be  affected.  The 
temporo-maxillary  articulation  becomes  the  seat  of  rheumatoid  arthritis  in 
about  25  per  cent,  of  the  total  number  of  cases.  At  a  later  period  the 
articulations   of   the   spine  may  become   involved.      The  disease  usually 


RHEUMATOID  ARTHRI1IS.  485 

attacks  the  cervical  vertebrse  first,  causing  pain  at  the  back  of  the  neck, 
and  rendering  fixation  of  the  neck  and  rotation  of  the  head  difficult.  The 
dorsal  and  lumbar  vertebrse  may  be  next  affected,  so  that  in  bad  cases 
the  spine  may  be  converted  into  a  rigid  column.  Pain  may  be  very 
severe,  especially  at  night,  while,  on  the  other  hand,  the  case  may  proceed 
to  extreme  deformity  without  pain. 

Very  considerable  alteration  in  the  shape  of  the  joints  may  occur  from 
the  formation  of  osteophytes,  thickening  of  the  capsules,  and  retraction  of 
muscles.  The  cartilages  become  worn  away  at  the  centres,  and  the  ends 
of  the  bones  become  eburnated  by  attrition  and  chronic  osteitis.  In  such 
joints  grating  is  readily  obtained  by  rubbing  the  eburnated  ends  of  the 
bones  against  each  other.  The  locking  of  the  joints,  which  sometimes 
ultimately  occurs,  is  not  due  to  true  ankylosis,  but  to  the  presence  of  the 
projecting  osteophytes,  and  to  the  thickening  of  the  capsules  of  the  joints. 
True  ankylosis  only  occurs  in  the  spinal  column  in  cases  of  rheumatoid 
arthritis.  Atrophy  of  the  muscles  from  disease  is  present  in  bad  cases, 
with  contractures  tending  to  flex  the  thigh  or  to  bend  the  knee  or  elbow. 
Most  patients  finally  reach  a  stage  in  which  the  disease  becomes  arrested, 
so  that  they  are  free  from  pain,  and  only  are  troubled  with  the  associated 
crippling  and  consequent  inconvenience.  Increased  rapidity  of  the  heart's 
action  is  a  not  uncommon  accompaniment  of  the  disease  in  its  earlier 
stages,  and  cold  and  moist  hands  and  feet  are  commonly  met  with. 
Subcutaneous  fibroid  nodules  and  periosteal  nodes  are  occasionally  met 
with,  especially  in  those  cases  which  are  secondary  to  rheumatism,  and  a 
rheumatoid  pigmentation  of  the  skin,  somewhat  resembling  freckles  in 
appearance,  is  not  unfrequently  seen.  In  a  small  proportion  of  cases  a 
neuritis  is  present,  but  it  probably  is  always  secondary  to  the  arthritis,  and 
may  be  caused,  as  suggested  by  Bannatyne,  either  by  the  existing  joint 
inflammatory  process,  or  by  the  action  of  toxines  circulating  in  the  blood. 
Spender  describes  the  following  collateral  synrptoms,  one  or  more  of  which 
are  commonly  present,  as  aids  to  diagnosis  in  doubtful  cases : — Tachy- 
cardia ;  pigmentation  of  the  face,  and  perhaps  numerous  spots  or  stains 
on  the  arms ;  cold  and  moist  hands ;  neuralgic  twinges  in  the  upper  and 
lower  limbs ;  persistent  neuralgic  pain  over  the  ball  of  the  thumb,  and  on 
the  ulnar  side  of  the  wrist. 

The  partial  or  monarticular  form. — This  form  is  met  with  especi- 
ally in  old  persons,  and  is  more  common  amongst  men.  It  is  most 
frequently  seen  in  the  knee,  hip,  shoulder,  and  spinal  column.  In  the  hip 
it  is  the  disease  known  as  morbus  coxce  senilis,  and  in  the  spine  it  is  known 
as  spondylitis  deformans.  The  cases  of  the  monarticular  form  are  especially 
apt  to  follow  an  injury  of  some  kind. 

Arthritis  deformans  in  children. — Still  describes  a  variety  in  which 
general  enlargement  of  the  joints  is  associated  with  swelling  of  the  lym- 
phatic glands  and  of  the  spleen.  It  occurs  nearly  always  before  the  second 
dentition,  and  more  frequently  in  girls.  It  generaliy  commences  in  an 
insidious  manner,  with  slight  stiffness  in  one  or  two  joints,  and  then  others 
gradually  become  involved  ;  but  the  onset  may  occasionally  be  more  acute, 
and  be  attended  with  fever.  The  enlargement  of  the  joints  is  due  more  to 
general  thickening  of  the  soft  tissues  than  to  enlargement  of  the  ends  of 
the  bones.     There  is  no  grating  to  be  obtained  in  the  joints. 

Diagnosis. — The  differential  diagnosis  of  gout,  rheumatism,  and 
rheumatoid  arthritis  is  a  matter  of  importance,  when  it  is  borne  in  mind 
that  the  treatment  of  these  three  diseases  is  quite  different.     Cases  are 


486  GENERAL  DISEASES 

frequently  diagnosed  as  cases  of  chronic  rheumatism  in  which  there  exist 
great  deformities — lipping  of  the  cartilages,  osteophytic  outgrowths,  and 
grating  of  the  ends  of  the  bones.  These  are  cases  of  rheumatoid  arthritis. 
In  chronic  rheumatism,  neither  lipping  of  the  cartilages  nor  the  osteophytic 
outgrowths,  which  are  so  diagnostic  of  rheumatoid  arthritis,  ever  occur. 

A  rough  clinical  test  in  the  diagnosis  of  a  chronic  articular  affection, 
but  one  which  is  frequently  of  assistance,  is  to  ascertain  the  effect  of 
treatment  with  salicylate  of  soda.  If  the  case  responds  well  to  this 
treatment,  it  is  most  probably  a  case  of  rheumatism.  If  it  does  not 
respond  to  this  treatment,  the  existence  of  rheumatoid  arthritis  or  gout  is 
fairly  certain,  as  neither  of  these  affections  responds  well  to  salicylates. 
It  is  highly  probable  that  the  oft-heard  remark  about  "  an  obstinate  case 
of  rheumatism  which  has  not  done  well  with  salicylates  "  is  due  to  the 
case  being  one  of  gout  or  of  rheumatoid  arthritis — more  probably  the 
latter. 

Eheumatism  in  its  subacute  or  chronic  forms,  and  especially  in  the 
form  known  as  rhumatisme  ftbreux,  certainly  may  affect  the  joints,  but  it 
never  produces  that  gross  permanent  deformity  which  the  other  affections 
may,  such,  especially,  as  the  lipping  of  the  cartilages  and  the  bony  out- 
growths already  referred  to.  In  the  condition  of  rhumatisme  fibreuxy 
fusiform  enlargement  of  the  small  joints  may  occur,  due  to  thickening  of 
the  joint  capsules,  but  there  is  an  absence  of  lipping  of  the  cartilages  and 
of  osteophytic  outgrowths.  The  actual  diagnosis  of  rheumatism  is  usually 
a  fairly  easy  matter.  If  a  patient  complains  of  pains  in  the  joints,  which 
pain  flies  about  from  joint  to  joint,  and  generally  affects  some  of  the 
muscles  at  the  same  time,  and  if,  in  connection  with  these  flying  pains, 
there  are  indications  of  the  presence  of  the  rheumatic  erythema — erythema 
nodosum — then  the  diagnosis  of  rheumatism  is  obvious.  As  a  rule,  the 
fitful  way  in  which  the  joints  are  affected,  the  fairly  rapid  subsidence  of 
the  swellings  of  the  joints,  and  the  association  of  muscular  pains,  make  the 
diagnosis  a  simple  matter.  Then  the  response  of  the  disease  to  treatment 
by  salicylates  will  settle  the  diagnosis. 

As  to  the  distinction  between  rheumatoid  arthritis  and  gout,  a  mistake 
is  more  likely  to  be  made,  but  it  should  be  avoided  if  some  patient  observa- 
tion be  given  to  the  case.  The  unfortunate  name  of  "  rheumatic  gout,"  as 
applied  to  rheumatoid  arthritis,  is  no  doubt  a  cause  of  gout  and  rheumatoid 
arthritis  being  confused.  The  following  distinguishing  characters  show 
how  very  different  are  the  two  diseases.  Eheumatoid  arthritis  occurs  most 
commonly  in  females,  gout  occurs  mostly  in  males.  Eheumatoid  arthritis 
occurs  most  commonly  amongst  the  poor  and  ill-nourished,  and  especially 
under  conditions  of  depressed  health,  prolonged  anxiety,  and  exposure  to 
damp  and  sudden  alterations  of  temperature ;  gout  mostly  among  the 
well-to-do  and  well-nourished.  Eheumatoid  arthritis  is  a  disease  which  is 
improved  by  good  dieting ;  in  the  case  of  a  gouty  person  a  spare  and  plain 
diet  is  indicated.  The  onset  of  rheumatoid  arthritis  is  insidious ;  that  of 
gout  sudden  and  obvious.  As  regards  the  commencement  of  the  attack, 
gout  most  commonly  begins  in  one  of  the  feet,  especially  in  the  great  toe 
joint ;  rheumatoid  arthritis,  although  ultimately  it  frequently  affects  many- 
joints  of  both  hands,  nearly  always  begins  in  one  joint,  most  commonly 
selecting  one  of  the  joints  of  the  thumb,  either  the  carpo-metacarpal  or 
metacarpophalangeal  joint,  after  which  it  rapidly  spreads  to  the  other 
joints.  In  the  joint  affections  of  rheumatoid  arthritis  there  is  no  obvious- 
swelling  at  first,  and  no  marked  redness ;  in  the  joint  affections  of  gout, 


RHEUMATOID  ARTHRITIS.  487 

at  the  commencement  of  acute  or  subacute  cases,  there  is  very  obvious 
swelling,  marked  redness,  and  a  shiny  condition  of  the  skin  around  the 
affected  joint.  In  rheumatoid  arthritis  there  is  very  little  pain  at  first. 
There  is  some  aching  in  the  joint,  but  the  affection  starts  in  a  very 
insidious  manner.  It  is  this  insidious,  character  of  the  disease  which  is 
one  of  its  bad  features,  for  the  patients  do  not  seek  advice  until  the 
affection  is  fairly  advanced.  Gout,  however,  begins  in  the  most  marked 
manner  with  severe  pain,  the  patient,  as  a  rule,  waking  up  in  the  early 
morning  with  excruciating  pain  in  the  great  toe.  Therefore,  if  doubt 
exists  as  to  whether  a  particular  case  be  one  of  rheumatoid  arthritis  or  of 
gout,  the  patient  should  be  questioned  as  to  the  commencement  of  the 
attack,  in  order  to  ascertain  whether  it  began  with  an  obvious  outburst  of 
pain,  and  with  swelling  and  redness  of  the  joint,  or  whether  it  began  very 
insidiously.  The  particular  joints  affected  in  the  two  diseases  assist  some- 
what in  the  differential  diagnosis.  Then  as  to  the  joint  affections,  in 
addition  to  the  general  statement  that  gout  generally  begins  in  the  foot, 
and  rheumatoid  arthritis  generally  in  the  hand,  an  important  factor  in  the 
differential  diagnosis  of  the  two  diseases  is,  that  there  is  a  joint  commonly 
affected  in  rheumatoid  arthritis  which  is  not  affected  in  cases  of  gout, 
namely,  the  temporo-maxillary  articulation.  The  writer  has  never  seen 
a  case  of  gout  in  which  the  temporo-maxillary  joint  has  been  affected, 
whereas  in  rheumatoid  arthritis  it  is  extremely  common  for  that  joint  to 
be  involved.  Another  distinction  is  this,  and  it  is  perhaps  one  of  the  most 
important,  namely,  that  in  connection  with  rheumatoid  arthritis  there  is 
a  remarkable  symmetry  in  the  affection  of  the  smaller  joints  of  the  hands. 
In  gout  that  symmetry  is  wanting.  It  was  this  symmetrical  affection  of 
the  joints  which  led  to  the  idea  that  rheumatoid  arthritis  is  a  nervous 
disease.  Lastly,  in  a  case  of  simple  rheumatoid  arthritis,  sodium  biurate 
is  not  found  in  the  joints  or  tissues,  whereas  in  the  gouty  person  sodium 
biurate  exists  in  the  affected  joints  and  frequently  in  other  tissues. 

It  is  not  common  to  have  rheumatoid  arthritis  and  gout  associated  in 
the  same  patient.  What  occasionally  does  occur  is,  that  gouty  deposits 
may  form  in  joints  suffering  from  rheumatoid  arthritis,  but  it  is  more  in 
the  nature  of  an  accident  than  anything  else.  A  person  suffering  from 
rheumatoid  arthritis  who  indulges  in  rich  living  for  a  lengthened  period  of 
time,  and  especially  if  he  takes  too  much  wine,  may  develop  gout,  and 
gouty  deposits  in  the  joints  of  a  patient  suffering  from  rheumatoid  arthritis 
may  occasionally  be  met  with.  Still,  it  is  only  a  complication ;  there  is  no 
actual  relationship  between  the  two  conditions,  and  one  in  all  probability 
does  not  predispose  to  the  other.  Eheumatism  certainly  predisposes  to 
rheumatoid  arthritis,  because  a  person  who  has  been  subject  to  rheumatism 
has  the  nutrition  of  the  joints  so  much  impaired  for  the  time,  that  if  there 
is  any  opportunity  for  the  specific  micro-organisms  to  gain  access  to  those 
joints,  it  is  very  likely  that  they  will  there  develop  and  flourish.  That  is 
probably  the  reason  why  rheumatoid  arthritis  is  not  uncommonly  met  with 
in  persons  who  have  previously  suffered  from  rheumatism. 

Prognosis. — In  the  early  stages  the  disease  is  curable,  if  prompt  and 
efficient  treatment  is  employed.  In  the  later  stages  the  prognosis  is  not 
so  good,  as  almost  the  best  that  can  then  be  expected  is  to  arrest  the 
disease  and  so  prevent  further  damage  to  the  joints. 

Treatment. — Eheumatoid  arthritis,  if  left  untreated,  tends  to  spread 
from  joint  to  joint,  and  produces  progressive  destruction  of  the  joint 
tissues.     Occasionally  treatment  fails  to  effect  any  arrest  of  the  disease, 


488  GENERAL  DISEASES. 

and  this  is  especially  apt  to  occur  in  connection  with  the  rheumatoid 
arthritis  of  the  old.  As  previously  stated,  the  disease  is  curable  in  the 
early  stages,  but  in  chronic  cases  the  best  that  can  be  expected  of  treat- 
ment is  that  the  progress  of  the  disease  shall  be  stopped,  and  that  a  fair 
amount  of  improvement  or  restoration  of  the  joints  shall  occur.  It  is 
doubtful  if  any  treatment  can  effect  complete  repair  of  the  disorganised 
tissues.  For  the  successful  treatment  of  this  disease,  it  is  essential  that 
the  treatment  should  be  commenced  while  the  disease  is  in  its  early 
stages ;  hence  the  importance  of  an  early  recognition  of  the  malady,  and 
of  its  distinction  from  gout  and  rheumatism.  The  treatment  must  be 
persevered  in  over  a  lengthened  period  of  time,  probably  a  year  or  two, 
and  during  the  treatment  everything  possible  must  be  done  to  increase 
the  patient's  strength.  The  not  infrequent  mistake  of  diagnosing  rheu- 
matoid arthritis  as  gout,  and  the  consequent  placing  of  the  patient  on 
a  restricted  and  spare  diet,  has  undoubtedly  led  to  the  development  of 
severe  and  incurable  forms  of  the  disease.  The  diet  should  be  as  liberal 
and  as  good  as  the  patient  can  digest,  and  animal  food  should  be  partaken 
of  freely,  though  not  to  the  exclusion  of  vegetables.  A  moderate  quantity 
of  wine  or  stout  should  be  taken  with  lunch  and  dinner.  Woollen 
clothing  should  always  be  worn  next  the  skin;  and  exercise,  short  of 
producing  pain,  should  be  indulged  in.  A  dry  gravel  soil  and  a  warm, 
dry  climate  are  most  suitable  to  patients  suffering  from  this  disease. 

The  treatment  of  rheumatoid  arthritis  by  drugs  must  be  quite  different 
from  that  of  gout  or  rheumatism.  Efficient  measures  must  be  taken  to 
improve  the  general  condition  and  health  of  the  patient.  Cod-liver  oil 
and  maltine  should  be  given  after  meals.  The  iron  preparations  in 
combination  with  arsenic  are  also  useful.  Garrod  strongly  recommends 
the  employment  of  iodide  of  iron.  In  addition  to  these,  the  two  drugs 
that  have  proved  to  the  writer  most  effectual  in  the  treatment  of  the 
disease  are  carbonate  of  guaiacol  and  methylene-blue.  Of  these  the 
carbonate  of  guaiacol  appears  to  be  the  more  efficient  remedy.  It  is  a 
white  crystalline  powder,  which  is  slowly  decomposed  in  the  intestinal 
tract,  the  liberated  guaiacol  being  absorbed  into  the  blood.  If  the  disease 
is  due  to  the  elaborated  poisons  of  micro-organisms,  then  it  is  possible 
that  the  guaiacol  may  destroy  or  render  inert  those  toxines.  The  carbonate 
of  guaiacol  should  be  given  in  cachets,  or  as  a  powder,  in  doses  gradually 
increased  from  5  to  10  grs.,  three  times  a  day.  Methylene-blue  should  be 
given  in  2-gr.  tabloids,  at  first  twice  a  day,  and  afterwards  three  times 
a  day.  A  patient  taking  methylene-blue  should  be  warned  that  the  urine 
and  faeces  will  be  stained  an  intense  blue  colour,  but  the  writer  has  never 
found  harm  to  arise  from  the  administration  of  the  drug.  After  the 
administration  of  methylene-blue  for  some  time,  the  conjunctival  mem- 
brane is  temporarily  stained  a  very  pale  blue  colour,  but  no  discoloration 
of  the  skin  occurs. 

The  thermal  treatment  of  the  affected  joints,  either  by  means  of  baths, 
superheated  air,  or  radiant  heat,  is  most  beneficial.  Douche  massage  is 
the  most  effective  form  of  treatment  with  hot  water,  and  perhaps  next 
to  that  ranks  the  peat  bath,  such  as  can  be  obtained  at  Strathpeffer. 
Radiant  heat  baths,  in  which  the  affected  joints  are  bathed  in  the  heat 
and  light  rays  reflected  from  a  number  of  incandescent  electric  lamps, 
are  also  beneficial  in  many  cases.  Electric  baths,  using  the  alternating 
current  either  from  an  alternating  dynamo  supply  or  from  an  induction 
coil,  are  also  most  useful  in  the  early  stages  of  rheumatoid  arthritis. 


RICKETS.  489 

Properly  regulated  movements  and  properly  applied  massage  are  of 
great  use  in  overcoming  the  stiffening  and  fixation  of  the  joints,  and  the 
muscular  wasting  in  their  vicinity.  Massage,  in  addition  to  its  local 
influence  upon  the  affected  joints  and  their  proximate  muscles,  also  improves 
the  general  circulation  and  the  general  nutrition  of  the  body.  General 
massage  should  therefore  be  lightly  applied  at  first,  little  or  no  attention 
being  paid  to  massage  of  the  affected  joints  for  the  first  few  days.  The 
form  of  manipulation  which  may  be  applied  to  the  joints  with  the  best 
results  is  massage  &  friction,  which  consists  of  the  application  of  quick 
frictions  or  rubbings  to  the  surfaces  of  the  joints.  In  addition,  gentle 
kneading  and  squeezing  of  the  parts,  particularly  of  the  tendons  and 
fibrous  surroundings,  should  be  effected.  The  effects  of  such  manipulations 
are  generally  evidenced  by  the  rapid  absorption  of  exudative  products  in 
and  around  the  joints.  Active  and  passive  movements  of  the  affected 
joints  should  also  be  employed. 

If  possible,  a  patient  suffering  from  rheumatoid  arthritis  should  not 
winter  in  this  country.  A  dry,  warm  atmosphere  is  required,  which  can 
be  best  obtained  in  Egypt  and  Algeria. 

If  the  locking  of  a  joint  is  extreme,  and  is  otherwise  incurable,  it  may 
be  advisable  to  excise  the  joint.  Successful  excisions  of  the  elbow  and 
knee  in  cases  of  rheumatoid  arthritis  have  been  performed. 

A.  P.  LUFF. 


RICKETS. 

Rickets  is  a  disease  of  infancy  and  early  childhood,  usually  commencing 
during  the  second  half  of  the  first  or  in  the  second  year  of  life ;  it  is  a 
disease  of  nutrition,  and  while  its  most  characteristic  feature  consists  in 
the  enlargement  of  the  epiphyses  and  other  deformities  of  the  bones,  the 
muscles,  ligaments,  and  various  internal  organs  are  usually  affected. 

Etiology. — In  considering  the  origin  of  rickets,  the  following  facts 
are  worthy  of  remark.  Rickets  is  a  rare  disease  among  the  peasants  of 
southern  Italy  and  in  other  warm  climates,  where  it  is  the  universal  cus- 
tom for  mothers  to  suckle  their  infants  for  the  first  year,  and  on  account 
of  the  favourable  climatic  conditions,  the  infant  is  able  to  spend  the  greater 
part  of  the  day  in  the  open  air.  Rickets  is  a  very  common  disease  in 
Lancashire  and  other  manufacturing  districts  in  this  country,  where  large 
numbers  of  infants  are  artificially  fed  either  wholly  or  in  part,  and  are 
exposed  to  the  unfavourable  conditions  of  a  cold  and  damp  climate,  and 
spend  a  great  part  of  their  time  in  the  unwholesome  air  of  crowded  dwellings. 
From  a  consideration  of  these  facts,  and  others  that  might  be  cited,  it  is 
tolerably  certain  that  the  chief  factors  in  producing  rickets  are  exposure 
to  cold  and  damp,  breathing  unwholesome  and  vitiated  air  in  dwelling- 
houses,  and  taking  food  which  in  quality  and  quantity  is  not  suitable  for 
the  delicate  digestion  and  assimilative  powers  of  the  infant.  On  the  other 
hand,  it  is  clear  that  the  powerful  factors  in  preventing  rickets  are  abund- 
ance of  fresh  air  and  sunlight,  well  warmed  and  ventilated  dwelling- 
houses,  and  breast-feeding  for  the  greater  part  of  the  first  year  of  life. 

It  is  important  to  note  that,  while  Italian  infants  do  not  suffer  from 
rickets  when  born  and  reared  in  their  native  country,  they  are  apt  to 
suffer  more  or  less  severely  when  born  and  bred  in  large  cities  and  in 


49Q  GENERAL  DISEASES. 

colder  countries  than  their  own,  even  though  they  are  suckled  by  their 
mothers.  This  is  true  of  Italian  infants  in  New  York  (Holt),  and  also  in 
this  country.  Negro  infants  appear  also  to  suffer  far  more  severely  than 
the  white  American  children  in  cities  like  New  York  and  Boston.  Pre- 
sumably the  infants  belonging  to  the  southern  races  are  more  sensitive  to 
the  influence  of  cold  and  damp,  than  the  infants  of  those  who  are  natives 
of  the  country.  Doubtless  the  negro  population  and  the  Italian  working- 
class  population  are  among  the  poorest  and  worst  housed  classes  in  the 
northern  American  cities.  It  must  be  borne  in  mind  that  in  this 
country  infants  who  are  nursed  by  a  healthy  mother  for  the  first  eight  or 
nine  months  of  life  mostly  escape  becoming  rickety,  yet  a  minor  degree  of 
rickets  is  not  uncommonly  seen  in  infants  who  are  breast-fed,  especially 
in  thos$  in  whom  lactation  has  been  prolonged  for  upwards  of  a  year. 
Breast-fed  infants  share  the  same  insanitary  conditions  as  artificially  fed 
infants,  as  far  as  exposure  to  cold  and  the  bad  air  of  dwelling-houses  are 
concerned,  and  indeed  often  suffer  more  from  exposure,  as,  being  dependent 
on  their  mothers  for  their  food,  they  are  taken  about  wherever  the  mother 
goes.  From  the  evidence  before  us  it  is  clear  that  rickets  is  certain  to  be 
a  common  disease  among  the  lower  classes  of  a  manufacturing  district, 
crowded  together  in  courts  and  slums ;  where  the  mothers  from  necessity 
or  choice  are  unable  to  suckle  their  infants,  and  give  them  a  mother's  care ; 
where  the  infant  is  badly  clothed,  carelessly  fed,  and  exposed  to  all  the  various 
bad  influences  which  ignorance  and  carelessness  produce.  Eickets  will  be 
a  rare  disease  where  the  mother  is  strong  and  healthy,  able  both  to  suckle 
the  infant  and  devote  her  time  to  its  care  and  nurture ;  where  the  climatic 
conditions  are  favourable,  and  the  infant  is  given  fresh  air  and  protected 
from  the  effects  of  cold  and  damp. 

We  may  briefly  summarise  the  chief  causes  of  rickets  as  : — 

1.  Dietetic. — The  infant,  during  the  first  six  or  nine  months,  has  been 
improperly  fed,  or,  as  the  result  of  chronic  dyspepsia,  has  been  unable  to 
digest  and  assimilate  its  food.  Very  probably,  as  the  result  of  indigestion, 
certain  deleterious  substances,  perhaps  toxines,  have  been  formed  in  the 
alimentary  canal  and  absorbed  into  the  blood. 

2.  Clirnatic  and.  hygienic. — The  infant  has  been  badly  clothed  and 
exposed  to  cold  and  damp,  or  for  many  months  together  has  lived  in 
stuffy  overheated  rooms.  The  dwelling-house  may  be  overcrowded,  and 
the  air  constantly  vitiated  by  the  excretions  of  the  dwellers.  As  a  result, 
the  infant  suffers  from  bronchial  and  gastro-intestinal  catarrh. 

3.  Congenital  weakness. — Infants  who  are  born  prematurely,  or  whose 
parents  are  weakly,  are  more  likely  to  suffer  than  vigorous  and  healthy 
infants. 

With  regard  to  the  question  of  improper  food,  there  is  much  perhaps 
that  requires  elucidation.  Woman's  milk,  when  produced  under  healthy 
conditions,  is  the  only  food  suitable  for  an  infant  for  the  first  eight  or  nine 
months  of  life,  and  the  more  nearly  an  artificial  food  approaches  in  com- 
position to  an  average  specimen  of  human  milk,  the  more  suitable  it  is  for 
the  wants  of  the  infant.  Woman's  milk  may  from  time  to  time  be  too 
rich  or  too  poor  in  composition,  and  the  infant  may  suffer  in  consequence, 
but  such  an  infant  suffers  infinitely  less  than  the  infant  fed  on  cow's  milk 
or  on  one  or  more  of  the  many  varieties  of  tinned  foods  so  readily  pro- 
cured. 

Eickets  has  been  attributed  with  more  or  less  show  of  reason  to  the 
excessive  use  of  starchy  foods  during  the  first  year  of  life,  to  the  use  of 


RICKETS.  491 

sweetened  condensed  milk,  which  contains  an  excessive  quantity  of  sugar, 
while  poor  in  fat  and  digestible  proteids.  Eickety  infants  usually  do  not 
waste  and  become  atrophic,  it  is  tolerably  certain  they  can  store  away 
carbohydrates  in  the  form  of  subcutaneous  fat,  but  their  digestion  is 
readily  overworked  as  regards  the  curd  of  cow's  milk  and  perhaps  also  the 
fat ;  the  curd  of  cow's  milk  is  apt  to  decompose  rather  than  digest  in  the 
infant's  stomach  and  intestines,  when  the  digestive  powers  are  weak  or  a 
catarrh  is  present.  But  in  the  present  state  of  our  knowledge  it  is  im- 
possible to  say  in  what  way  improper  feeding  produces  rickets.  It  may  be 
as  stated,  proteid-fat-starvation,  or  it  is  not  at  all  improbable  that  the 
fermentation  taking  place  in  the  alimentary  canal  forms  bye-products 
or  toxines,  which  being  absorbed  into  the  blood  are  responsible  for  some 
at  least  of  the  symptoms  and  phenomena  of  rickets. 

Morbid  anatomy. — The  chief  lesions  found  post-mortem  in  those 
dying  during  the  active  stage  of  the  disease  consist  in  very  important 
changes  in  the  bones,  the  conditions  varying  according  to  the  stage  and 
severity  of  the  disease.  As  a  rule,  the  bones  which  exhibit  these  changes 
most  strikingly  in  the  early  stages  are  the  bones  forming  the  roof  of  the 
skull,  the  sternal  ends  of  the  ribs,  and  the  lower  end  of  the  radius ;  and 
these  bones  should  be  examined  carefully  at  the  post-mortem,  when  rickets 
is  believed  to  be  present.  These  bones  are  the  first  to  be  affected,  and  show 
pathological  changes  in  the  early  stages  of  the  disease.  Speaking  generally, 
rickety  bones  are  readily  cut  with  a  knife  on  account  of  the  comparatively 
small  amount  of  mineral  matter  they  contain ;  they  are  softer  and  have  much 
less  rigidity  and  elasticity  than  normal  bone.  An  examination  of  a  rib  in 
a  case  of  severe  rickets,  say  of  a  child  in  its  second  year,  will  show  a  con- 
siderable enlargement  of  the  anterior  end  where  it  joins  its  cartilage,  the 
swelling  being,  perhaps,  more  prominent  on  the  pleural  than  cutaneous 
side ;  the  rib  will  have  lost  most  of  its  elasticity,  it  can  be  readily  bent  or, 
perhaps,  "  kinked  "  or  snapped  in  two  when  sharply  bent  by  the  fingers. 
Section  through  the  swelling  made  longitudinally  will  show  the  swelling  to 
consist  of  cartilage,  with  islands  of  calcification  and  much  red  hemorrhagic 
spongy  bone  on  the  rib  side  of  the  swelling.  An  examination  of  a  radius 
may  show  a  very  striking  enlargement  of  the  lower  end  which  involves 
the  cartilaginous  epiphyses  and  more  or  less  of  the  adjoining  shaft. 
Longitudinal  section,  can  readily  be  made  by  a  strong  knife  through  the 
enlarged  carpal  end,  the  swelling  is  made  up  (as  noted  in  the  rib)  of 
cartilage,  and  a  broad  irregular  zone  of  mixed  calcified  bone  and  cartilage. 
The  centre  of  ossification  in  the  epiphyses  is  usually  not  present  in  children 
under  eighteen  months  of  age.  The  shaft  of  the  bone  readily  yields  to 
pressure  and  bends,  and  if  the  rickety  changes  are  well  advanced,  can  be 
"  kinked  "  or  fractured  between  the  fingers. 

In  explanation  of  these  appearances,  we  must  bear  in  mind  that  normal 
growth  of  bone — which  is  very  active  during  the  first  two  or  three  years — 
is  effected,  in  length,  by  the  proliferation  of  the  cartilage  cells  and  ossifica- 
tion proceeding  at  the  ends  of  bones  near  the  junction  of  the  epiphyses 
and  shaft ;  in  thickness,  by  the  formation  of  new  compact  bone  around  the 
shaft  by  the  periosteum,  while  absorption  is  going  on  in  the  medullary 
cavity,  increasing  its  size  as  growth  proceeds.  According  to  Quain,  in  the 
human  subject,  the  growth  of  the  long  bones  is  chiefly  in  length,  between 
the  first  and  fourth  years.  The  growth  and  nutrition  of  bone  is  pro- 
foundly disturbed  in  the  active  stages  of  severe  rickets.  The  proliferating 
or  growing  zone  at  the  ends  of  the  bones — more  especially  the  anterior 


492  GENERAL  DISEASES. 

end  of  the  ribs  and  carpal  end  of  the  radius — is  immensely  increased  in 
depth  and  width,  giving  rise  to  the  enlargement,  while  instead  of  true 
cancellous  bone  being  formed,  lime  salts  are  deposited  in  an  irregular  and 
erratic  manner,  and  irregular  cavities  are  formed  in  the  swollen  cartilage 
containing  grumous  material.  Beneath  the  periosteum  marked  changes 
take  place,  and  instead  of  hard  compact  bone  being  formed,  the  outside 
ring  of  bone  consists  of  partially  calcified  fibro-cellular  tissue ;  if,  then,  as 
frequently  takes  place,  there  is  an  abnormal  widening  of  the  medullary 
canal,  it  is  easy  to  understand  how  the  bone  loses  its  elasticity  and  readily 
bends  and  breaks. 

The  vault  of  the  skull  in  a  rickety  child  in  the  early  stages  is  easy  to 
remove  at  the  post-mortem,  as  far  as  cutting  through  the  bones  is 
concerned.  The  bony  tissue  corresponding  to  the  protuberances  of  the 
frontal  and  parietal  bones  is  thicker  than  normal,  but  consists  of  cancellous- 
like  spongy  tissue,  readily  cut  by  a  knife.  The  edges  of  the  bones  are  also 
thickened,  but  are  soft  and  cut  quite  easily,  as  there  is  often  an  almost 
complete  absence  of  lime  salts.  The  ridges  on  the  occipital  bone  are 
well  marked,  and  the  bone  is  sometimes  flattened  in  from  pressure  of  lying 
on  the  back  of  the  head.  Cranio-tabes  is  more  common  before  six  months 
of  age  than  after ;  it  is  seen  mostly  in  the  occipital  bone  or  posterior  part 
of  the  parietal.  It  is  readily  identified  by  stripping  the  dura  mater  off  the 
occipital  or  parietal  bone  and  holding  it  up  to  the  light ;  small,  translucent 
patches  will  be  seen  where  the  bone  is  thin  or  absent. 

The  subsequent  changes  which  the  bone  undergoes  depends  upon  the 
course  of  the  disease.  In  the  worst  cases  the  bones  remain  for  months, 
perhaps  into  the  third  year,  in  a  soft  and  partially  calcified  state.  They 
easily  bend  and  undergo  deformities,  or  they  may  be  the  subject  of 
multiple  fractures.  If  the  rickety  changes  are  severe,  the  growth  of  the 
bones  is  checked,  the  proliferating  process  at  the  ends  of  the  long  bones 
is  interfered  with,  growth  afterwards  is  slow,  and  the  individual  is  certainly 
stunted.  In  the  worst  cases  the  abnormal  curves,  as  those  of  the  tibia 
in  bow  legs,  remain,  the  bones  harden  by  the  deposition  of  lime,  and  the 
curve  becomes  permanent.  In  the  slighter  cases  the  swelling  of  the 
epiphyses  gradually  disappears,  and  the  curves  noted  in  the  tibia  and 
other  bones  gradually  straighten  out  as  growth  proceeds,  and  tend  towards 
normal. 

Symptoms. — In  the  vast  majority  of  cases  of  rickets,  the  first 
symptoms  of  the  disease  are  noted  during  the  second  six  months  of  life,  or 
shortly  after ;  though  the  results  of  rickets  may  be  seen  in  the  softness  and 
deformities  of  the  bones,  with  muscular  weakness,  long  after  this  period, 
and  indeed,  as  far  as  stunted  limbs  are  concerned,  throughout  life.  During 
the  first  six  months  of  life,  the  activities  of  the  infant,  as  far  as  muscular 
movements  are  concerned,  are  small;  neither  the  muscles  nor  the  ligaments 
or  the  bones  of  the  limbs  undergo  much  active  development.  But  after 
this  period  has  elapsed  a  marked  development  of  the  locomotive  apparatus 
begins,  the  infant  holds  up  its  head  firmly,  gradually  manages  to  sit  up 
fairly  well  without  support,  and  by  the  end  of  the  first  year  is  making 
vigorous  attempts  to  crawl  and  get  upon  its  legs.  It  is  during  this  period 
of  active  development  of  the  bones  and  voluntary  muscles  that  rickets 
occurs,  and  it  is  the  locomotive  apparatus  that  is  largely  affected. 

Early  symptoms. — The  early  symptoms  of  the  disease  are  indefinite, 
and  in  the  slighter  cases  of  rickets  are  either  overlooked  or  are  absent. 
The  first  characteristic  sign  of  rickets  is  the  enlargement  of  the  epiphyses 


RICKETS.  493 

of  the  ribs  and  bones  of  the  wrist,  and  the  thickening  of  the  parietal 
and  frontal  eminences.  But  before  these  enlargements  take  place,  or 
are  well  marked,  the  disease  must  have  been  in  progress  for  some  time, 
but  the  symptoms  which  occur  during  this  period  are  mostly  ill  defined. 
One  of  the  earliest  symptoms  which  arouses  suspicion  of  the  onset  of 
rickets,  and  which  is  always  present  in  severe  cases,  is  excessive  sweating. 
This  is  most  noticeable  about  the  head  and  during  sleep,  but  the  perspira- 
tion is  general,  and  often  followed  by  plentiful  crops  of  sudamina,  which 
the  mother  probably  describes  as  a  "  teething  rash."  Beads  of  perspiration 
may  be  seen  to  stand  out  on  the  infant's  forehead,  and  its  underclothes  or 
night  dress  may  become  damp  or  wet.  There  is  a  notable  restlessness  of 
the  infant  during  what  should  be  the  sleeping  hours,  it  is  uncomfortable, 
kicks  off  its  clothes,  and  its  nurse  complains  that  it  is  a  bad  sleeper  and 
requires  constant  attention  and  feeding  at  night.  Its  hair  is  often  partially 
worn  off  the  back  of  its  head  by  its  restlessness  and  rolling  its  head  about. 
There  is  always  a  distended  state  of  the  intestines  with  gas,  due  to 
fermentative  changes  in  the  small  intestine  and  stomach,  with  loss  of  tone 
of  the  muscular  fibre  of  the  intestines  and  abdominal  walls ;  the  abdomen 
looks  large  and  round  in  consequence.  It  is  probable  also  that  the  infant 
suffers  from  constipation,  or  the  stools  are  large  and  putty-like.  It  is 
clear  that  these  symptoms  are  due  to  gastro-intestinal  dyspepsia,  and  the 
sweating  suggests  absorption  of  toxines  from  the  alimentary  canal.  While 
the  sweating  and  restlessness  suggest  the  onset  of  rickets,  if  with  these 
symptoms  the  appearance  of  the  teeth  is  delayed,  and  the  infant  shows 
little  disposition  to  muscular  exertion,  and  makes  no  attempt  to  sit  up  or 
perhaps  hold  up  its  head  when  eight  or  nine  months  old,  the  suspicion  of 
rickets  will  be  confirmed.  It  many  cases,  at  least,  at  this  period,  not  only 
is  there  no  attempt  at  sitting  up  and  a  backwardness  in  the  use  of  its 
limbs,  but  it  resents  being  moved  and  jumped  about,  and  there  is  a  certain 
indefinite  tenderness  of  the  bones  of  the  limbs.  Peritoneal  tenderness  is  a 
sign  of  scurvy  rather  than  rickets,  but  as  scurvy  so  frequently  occurs  in 
conjunction  with  rickets,  it  is  a  noteworthy  symptom. 

Convulsions  are  among  the  early  symptoms  of  rickets  which  may  be 
present.  The  convulsions  are  usually  frequent  rather  than  severe,  and  are 
likely  to  be  looked  upon  as  teething  fits.  They  are  of  the  ordinary  type 
of  infantile  convulsions,  the  clonic  spasms,  i.e.  the  muscular  twitchings  of 
the  face  and  limbs  being  well  marked,  without  perhaps  any  severe  tonic 
spasms,  i.e.  stiffening  of  the  limbs.  There  may  be  no  obvious  exciting 
cause,  but  this  is  usually  to  be  found  in  the  alimentary  canal.  Spasm  of 
the  glottis  may  occur  in  connection  with  the  convulsive  fits  described  later. 

Characteristic  signs. — It  has  already  been  remarked  that  in  many 
cases,  notably  the  less  severe,  the  early  symptoms  are  absent  or  over- 
looked, and  it  is  only  when  there  is  obvious  deformity  of  the  bones  that 
the  disease  is  suspected.  It  may  happen  that  a  fat  infant  of  a  year  old, 
entirely  breast  fed,  showing  signs  of  muscular  weakness  and  enlarged 
epiphyses,  is  brought  for  medical  advice,  and  no  history  of  sweats  or 
dyspepsia  can  be  elicited.  But  in  severe  cases  it  is  almost  certain  that 
what  have  already  been  described  as  early  symptoms  will  be  present.  The 
beading  of  the  ribs  is  mostly  the  earliest  discoverable  change  in  the  bones, 
and  it  is  almost  constantly  present.  The  anterior  ends  of  the  ribs  where 
they  join  the  cartilages  are  more  or  less  swollen,  and  can  be  readily  felt, 
and  also  seen  if  the  infant  is  not  too  fat.  The  swelling  involves  both  the 
pleural  as  well  as  the  costal  side,  and  indeed  is  often  more  prominent  on 


494  GENERAL  DISEASES 

the  former  than  the  latter.  This  beading  is  mostly  present  at  the  eighth  or 
ninth  month,  but  may  be  often  noted  earlier  than  this.  In  addition  to  the 
beading  of  the  ribs,  a  vertical  depression  or  shallow  groove  is  frequently 
present  on  each  side  of  the  sternum,  involving  a  part  of  both  ribs  and 
cartilages,  and  caused  by  softening.  The  chest  wall  here  is  sucked  in 
during  inspiration,  the  sternum  is  thrust  forward,  increasing  the  antero- 
posterior diameter  and  diminishing  the  transverse.  Any  bronchial  catarrh 
or  obstruction  to  the  air  entering  the  chest  will  naturally  tend  to  make  the 
deformity  worse.  In  some  cases,  instead  of  the  above,  a  shallow  transverse 
depression  perhaps  two  inches  broad  is  seen  passing  round  the  chest  on  a 
level  with  the  tip  of  the  sternum,  and  caused  by  the  contractions  of  the 
diaphragm  during  inspiration,  drawing  in  the  softened  ribs,  and  perhaps 
everting  the  lower  edges  of  the  chest  wall  (Harrison's  sulcus). 

The  skull  early  shows  change  of  shape  due  to  rickets ;  there  is 
thickening  of  the  edges  of  the  bones,  and  this  is  especially  true  of  the 
parietal  bones ;  there  is  a  marked  exaggeration  of  the  frontal  and  parietal 
eminences,  with  a  flattening  of  the  vault  of  the  skull,  so  that  the  head 
looks  large  and  square.  In  some  cases  there  are  shallow  grooves  corre- 
sponding with  the  sagittal  and  coronal  sutures,  which  give  the  top  of  the 
skull  a  "  hot-cross-bun  "  appearance.  The  f ontanelles  are  widely  open  long 
after  they  should  be  closing  up.  Less  characteristic  of  rickets  are  the 
atrophic  changes  sometimes  present,  and  which  consist  of  small  patches, 
more  especially  in  the  occipital  bone,  where  the  bone  is  thin  or  deficient, 
and  can  be  compressed  with  the  pressure  of  a  finger.  This  atrophy  of 
bone  has  been  called  cranio-tabes,  and  may  be  felt  in  very  young  infants ; 
it  is  doubtful  if  it  is  always  pathognomonic  of  rickets. 

Sooner  or  later,  in  most  cases,  an  enlargement  of  the  epiphyses  at  the 
wrists  takes  place,  and  similar  changes  occur  at  the  ankle,  and  also  at  the 
ends  of  the  bones  forming  the  knee.  All  these  deformities  are  practically 
always  symmetrical. 

The  soft  flabby  condition  of  the  muscles  is  hardly  less  characteristic  of 
the  disease  than  the  enlargement  of  the  epiphyses.  In  some  cases  the 
muscular  paresis  and  helplessness  of  the  infant  is  the  most  noteworthy 
feature  of  the  case.  The  infant  at  twelve  months  of  age  may  be  very  helpless, 
and  not  offer  to  sit  up  at  all  by  itself.  At  this  time,  if  the  case  is  at  all 
severe,  the  infant  presents  a  very  characteristic  appearance.  The  head 
is  large  and  square,  with  widely  open  fontanelles ;  the  gums  are  toothless, 
the  ribs  are  beaded,  the  chest  is  narrow,  the  sides  falling  in  during  in- 
spiration; the  epiphyses  at  the  wrists  and  ankles  are  enlarged.  The 
abdomen  is  large  and  round  from  distension  of  the  intestines  with  gas,  and 
contrasts  notably  with  the  contracted  chest.  The  muscles  are  soft,  weak, 
and  badly  developed,  and  the  infant  cannot  sit  up,  or  does  so  with 
difficulty.  The  skin  is  moist,  and  perhaps  covered  with  sudamina.  In 
many  cases  the  disease  is  far  less  well  marked  than  this.  The  head  may 
be  fairly  well  formed,  while  the  ribs  are  beaded,  and  the  epiphyses 
enlarged  ;  or  the  deformities  not  well  marked,  while  the  muscular  weakness 
is  excessive.  Convulsions  or  laryngismus  may  be  a  marked  feature  of  the 
case,  or  they  may  be  entirely  absent. 

As  the  infant  grows  older,  other  deformities  than  those  already 
mentioned  make  their  appearance.  On  account  of  the  deficiency  of 
mineral  matter,  the  long  bones  yield  to  pressure  more  easily  than  healthy 
ones,  and  curves  or  bends  are  produced.  The  ribs  perhaps  become  bent  or 
kinked  at  their  angles,  the  clavicle  in  severe  cases  bends  like  a  letter  S,  and 


RICKETS.  495 

the  edges  of  the  scapula  are  thickened.  The  shafts  of  the  bones  of  the  limbs 
bend  as  they  come  to  be  used  for  sitting  on  the  floor,  or  attempts  at  standing 
and  crawling  are  made — the  most  marked  being  the  tibia  and  fibula.  The 
curves  vary  in  position  and  degree,  but  usually  the  concavity  is  on  the 
inner  side  (bow-legs),  the  lower  part  of  the  bone  becoming  turned  inwards 
by  the  child  sitting  cross-legged  on  the  floor.  The  femur  usually  bends 
with  its  convexity  forwards  or  outwards,  and  the  humerus  may  bend  in  a 
similar  way.  The  bones  of  the  forearm  are  less  often  misshapen ;  the  curves 
usually  are  an  exaggeration  of  the  normal  ones,  and  may  be  produced  by 
the  child  crawling  about  the  floor  and  resting  some  of  its  weight  on  the 
forearms.  In  the  more  severe  cases  of  rickets  the  limbs  are  shorter  than 
those  of  a  healthy  child,  in  consequence  of  the  rickety  changes  in  progress 
at  the  growing  end  of  the  bones ;  growth  is  interfered  with,  and  the  stature 
becomes  stunted,  while  the  hands  and  feet  are  often  disproportionately  large. 
In  some  Lancashire  villages  inhabited  by  a  coal-mining  or  manufacturing 
population,  large  numbers  of  stunted  bow-legged  children  will  be  seen  in 
the  streets,  while  the  adult  population,  especially  the  men,  are  seen  to  be 
very  much  under  the  average  height,  some  being  actually  dwarfs. 

When  the  child  has  learnt  to  sit  up  perhaps  at  18  months  or  2  years  of 
age,  the  spinal  column  is  apt  to  give  way  on  account  of  weakness  of 
the  ligaments  and  muscles,  the  natural  curves  becoming  lost  in  a  general 
bowing  of  the  spine  backwards  (kyphosis),  this  backward  curve  extending 
from  the  upper  dorsal  to  the  lower  lumbar.  The  curve  is  very  apparent 
when  the  child  sits  up,  and  is  straightened  out  if  the  child  is  suspended  or 
by  extending  the  spine. 

The  bones  may  not  only  bend  but  break  in  the  severe  forms  of 
rickets.  The  fracture  is  usually  of  the  "  green-stick "  variety,  that  is, 
the  bone  breaks  and  is  "  kinked  "  at  the  fracture,  the  ends  being  held 
together  by  the  fibrous  or  non-calcified  substance  of  the  bone.  The  fractures 
are  very  likely  to  be  multiple,  being  present  at  the  angles  of  the  ribs, 
clavicle,  humerus,  radius,  or  indeed  any  of  the  bones. 

Eickets  is  essentially  a  chronic  disease,  and  at  best  improvement  is 
very  slow,  while  in  a  large  number  of  cases,  especially  where  under 
unsuitable  hygienic  conditions,  any  decided  improvement  is  long  delayed. 
The  more  active  phases  of  the  disease,  profuse  sweating,  restlessness  at 
night,  chronic  dyspepsia,  constipation,  may  perhaps  be  greatly  improved 
in  the  course  of  a  few  months  by  careful  dieting  and  residence  in  hospital, 
or  still  better  at  some  seaside  home.  The  muscular  weakness,  deformities 
of  the  epiphyses  and  shafts  of  the  bone,  do  not  so  quickly  disappear.  That 
the  ligaments  are  weak  and  more  or  less  softness  of  the  bones  remain  for 
a  long  time,  is  shown  by  the  fact  that  knock-knees  and  flat  feet  develop 
after  the  child  has  been  able  to  stand  and  also  walk.  Gradually,  however, 
the  bones  consolidate,  the  head  rounds  off  to  a  more  normal  shape,  the  swollen 
ends  of  the  long  bones  become  smaller,  and  the  lesser  degrees  of  curvature 
as  in  the  tibia  and  fibula  become  less  marked.  The  consolidation  of 
rickety  bones  is  often  accompanied  by  an  ivory-like  condensation  of  the 
bone  substance.  In  the  worst  cases  the  deformity  of  the  shafts  of  the 
femur,  tibia,  and  fibula  become  permanent  unless  their  shape  is  restored  by 
the  surgeon. 

Associated  conditions. — Having  given  a  sketch  of  the  chief  signs  and 
symptoms  characteristic  of  rickets,  there  remain  to  be  described  some 
associated  conditions,  which,  though  they  form  no  essential  part  of  the 
complaint,  are  often  present : — 


496  GENERAL  DISEASES. 

Bronchial  catarrh. — It  is  exceedingly  common  among  the  out-patients 
of  a  children's  hospital  to  see  infants  a  year  or  more  of  age  suffering 
from  bronchial  catarrh,  and  who  show  signs  of  rickets  of  moderate  severity. 
The  respiratory  movements  are  increased  in  number,  there  is  rhonchus  and 
wheezing  to  be  heard  over  the  chest,  the  ribs  are  beaded,  and  the  sides 
of  the  chest  forming  the  anterior  ends  of  the  ribs  are  falling  in  at  every 
inspiration.  Undoubtedly  the  association  of  rickets  and  chronic  bronchial 
catarrh  is  a  very  common  one  ;  infants  who  are  rickety  are  very  sensitive 
to  cold,  readily  get  a  bronchial  catarrh,  and  the  catarrh  is  very  apt  to 
be  chronic.  Then  the  bronchial  attack  disturbs  the  digestive  organs,  and 
entails  close  confinement  to  the  house.  Acute  bronchitis  and  broncho- 
pneumonia are  very  fatal  diseases  in  rickety  infants  on  account  of  the 
want  of  rigidity  of  the  chest  walls,  and  the  feeble  power  of  the  muscles 
of  respiration. 

Ancemia. — In  most  cases  of  rickets  there  is  anaemia,  and  in  severe 
cases  the  paleness  of  the  infant  is  a  very  noticeable  feature.  Examina- 
tions of  the  blood  have  not  hitherto  yielded  any  very  decided  results, 
and  the  observations  of  different  observers  have  been  at  variance.  Hock 
and  Schlesinger  found  a  diminution  in  the  number  of  red  corpuscles 
(2,500,000  per  c.mm.),  and  an  increase  in  the  number  of  the  white 
corpuscles  (15,000-40,000  per  c.mm.).  In  connection  with  this  it  must 
be  remembered  that  in  infants  and  children  generally  the  white  corpuscles 
are  proportionately  more  numerous  than  in  adults.  The  same  authors 
found  an  average  of  60  per  cent,  of  haemoglobin  with  2,300,000  cells. 
When  the  ansemia  is  at  all  severe,  the  spleen  is  usually  enlarged. 
Eickety  deformities  are  very  frequently  present  in  the  anaemias  of 
infancy,  and  while  it  is  probable  in  some  of  these  cases  the  rickets  is 
secondary,  it  may  be  by  no  means  certain  in  a  given  case  whether  rickets 
is  the  cause  of  the  anaemia  or  secondary  to  it.  Thus,  in  the  condition 
known  as  anaemia  infantum  pseudoleukemia  there  is  grave  anaemia, 
much  enlarged  spleen,  moderate  or  extensive  leucocytosis,  and  the  majority 
of  cases  display  enlarged  epiphyses  to  a  marked  or  moderate  extent. 
When  the  anaemia  is  severe  and  the  evidence  of  rickets  slight,  it  is 
tolerably  safe  to  assume  that  the  rickets  is  secondary  to  the  blood  disease. 

Laryngismus. — Eeference  has  already  been  made  to  eclampsic  attacks 
as  often  occurring  in  rickety  infants  among  the  early  symptoms,  perhaps 
before  the  enlarged  epiphyses  are  very  obvious.  Child-crowing  or 
laryngismus  may  also  occur  early  in  the  disease,  say  at  the  eighth  or  ninth 
month  or  a  few  months  later,  and  may  persist  for  many  months.  The 
symptoms  are  due  to  spasm  of  the  glottis ;  when  the  spasm  of  the  adduc- 
tors partially  closes  the  glottis,  inspiration  is  accompanied  by  a  crowing 
sound;  when,  as  sometimes  happens,  the  spasm  is  complete,  there  is  a 
momentary  "catch  in  the  breath,"  followed  by  evident  distress  and 
struggling;  the  infant  becomes  of  a  dusky  colour,  then  the  labouring 
inspiratory  muscles  succeed  in  forcing  open  the  glottis  with  perhaps  a 
long-drawn  crowing  breath.  These  attacks  are  commonest  in  those 
children  who  have  been  much  confined  to  the  house,  and  there  is  in  some 
instances  an  attendant  bronchial  catarrh,  while  all  are  associated  with 
rickety  deformities  and  chronic  indigestion.  There  are  usually  pale  putty- 
like stools  and  much  flatulence.  The  unstable  condition  of  the  respiratory 
centres  is  in  all  probably  due  to  toxines  absorbed  from  the  alimentary  canal. 

Tetany  is  a  form  of  tonic  spasm  affecting  the  limbs  or  muscles  of  the 
neck,  mostly  occurring  in  rickety  children. 


RICKETS.  497 

Enlargement  of  internal  organs. — The  liver  is  frequently  enlarged  in 
rickets,  both  in  the  early  and  late  stages.  In  palpating  the  liver, 
care  must  be  taken  not  to  mistake  the  displacement  downward  of  this 
organ — which  often  occurs  when  the  chest  is  deformed — for  enlargement. 
Enlargement  is  presumably  connected  with  the  indigestion  so  often 
present  in  rickets,  and  is  no  essential  part  of  the  disease.  Eeference  has 
already  been  made  to  enlargement  of  the  spleen  in  rickets ;  the  enlarge- 
ment is  proportional  to  the  anaemia  present,  and  not  to  the  severity  of  the 
rickets.  The  skull  is  often  of  a  larger  size  than  normal  in  rickets,  due  to 
thickening  of  the  parietal  and  frontal  bones ;  but  in  some  cases  at  least 
the  brain  is  above  normal  size  and  weight,  though  normal  in  appearance  to 
the  naked  eye. 

Scurvy. — Eickets  coexists  in  many  cases  of  infantile  scurvy ;  it  is  not 
universally  present,  but  in  the  experience  of  the  writer  the  two  are  found 
associated  together  oftener  than  some  recent  writers  will  allow.  In  some 
cases  of  rickets  of  the  severer  type  in  the  early  stages,  the  bones  are 
distinctly  tender,  and  the  child  resents  being  moved,  while  at  the  same 
time  there  is  no  other  evidence  of  scurvy  present.  In  cases  of  severe 
rickets  dying  of  broncho-pneumonia,  we  have  frequently  found  tiny 
hemorrhagic  effusions  on  section  through  the  ends  of  the  swollen  ribs. 
In  these  cases  rickets  was  presumably  associated  with  slight  scurvy. 

Dentition. — As  a  rule  in  rickets,  dentition  is  delayed,  perhaps  no  teeth 
making  their  appearance  during  the  first  year.  It  is  not  uncommon,  how- 
ever, to  find  that  the  lower  two  incisors  are  cut  at  the  usual  time,  seven 
or  eight  months,  and  then  a  long  delay  ensues  of  many  months.  The 
order  of  appearance  may  be  altered  in  rickets,  as,  for  instance,  the 
molars  appearing  before  any  of  the  lateral  incisors,  or  the  latter  before  the 
central  incisors.  It  is  usually  said  that  dentition  is  apt  to  give  rise  to 
more  trouble  in  rickety  infants  than  it  does  in  healthy  ones,  but  this  is 
only  another  way  of  saying  that  healthy  infants  are  less  troubled  by  tooth- 
getting  than  weakly  ones.  There  seems  to  be  no  constant  rule  with  regard 
to  the  condition  of  the  teeth  in  rickety  children  when  cut ;  certainly  in 
severe  rickets  the  teeth  when  cut  are  small  and  quickly  become  carious, 
and,  on  the  other  hand,  in  large  numbers  of  children  with  slight  rickets  the 
teeth  are  good. 

Chief  deformities,  Summary. — Head. — The  skull  bones  are  mostly 
affected  when  rickets  occurs  before  the  end  of  the  first  year ;  it  is  usually 
unaffected  if  rickets  supervenes  later.  The  frontal  and  parietal  eminences 
become  abnormally  prominent,  the  edges  of  the  bones  are  thickened,  the 
upper  surface  of  the  skull  is  flattened,  the  shape  of  the  head  becomes 
square,  with  a  circumference  larger  than  normal. 

Chest. — Beading  of  the  ribs  is  an  early  symptom,  and  may  be  followed 
by  deformities  of  the  chest  wall ;  there  is  a  broad  vertical  groove  on  each 
side  of  the  sternum,  where  the  ribs  and  cartilages  have  fallen  in,  while  the 
sternum  and  a  portion  of  the  cartilages  have  been  thrust  forward.  Instead 
of  the  above,  there  is  a  broad  transverse  groove  (Harrison's  sulcus)  on  each 
side  of  the  chest  nearly  on  a  level  with  the  lip  of  the  sternum,  and  corre- 
sponding with  the  attachment  of  the  diaphragm.  The  lower  edge  of  the 
chest  wall  is  everted. 

Upper  limb. — In  the  clavicle  there  may  be  an  exaggerated  curve  back- 
wards at  the  outer  and  a  similar  curve  forward  at  the  inner  end ;  the  ends 
are  thickened.  The  edges  of  the  scapulae  may  be  thickened.  The  humerus 
may  be  bent,  the  convexity  outwards,  produced  by  the  friends  raising 
vol.  i. — 32 


498  GENERAL  DISEASES. 

the  child  by  its  arms ;  possibly  the  muscular  action  of  the  deltoid  may 
also  effect  this.  The  radius  and  ulna  may  be  affected  in  a  similar  manner, 
being  bent  outwards  and  twisted  by  the  child  crawling  on  all-fours. 

Lower  limb. — The  deformities  of  the  lower  limb  are  more  severe  and 
more  important  than  those  of  the  upper,  on  account  of  the  legs  having  to 
sustain  the  weight  of  the  body.     The  chief  deformities  are  the  following : — 

Coxa  vara  or  a  curvature  of  the  neck  of  the  femur  downwards  and 
forwards,  the  result  of  giving  way  in  consequence  of  the  femurs  sustaining 
the  weight  of  the  body ;  as  a  result  the  leg  is  everted,  and  there  is  an 
awkward  waddling  gait ;  the  trochanter  is  felt  higher  than  usual,  and  the 
legs  are  shortened.  Curvature  of  the  shaft  of  the  femur  with  the  con- 
vexity forwards  and  outwards,  with  rotation  of  the  lower  half,  overgrowth 
of  the  internal  condyle  and  perhaps  undergrowth  of  the  external  giving 
rise  to  knock-knees.  Curvature  of  the  shaft  of  the  tibia,  the  convexity 
being  outwards  (bow  legs) ;  this  may  affect  the  tibia  as  a  whole,  or  more 
especially  the  lower  third.  Eotation  may  also  take  place.  Overgrowths 
on  the  tibia  are  common  along  the  borders  or  at  the  internal  condyle  or 
immediately  below  it.  Flat  foot  is  very  common;  many  of  the  deformities 
of  the  lower  limb  take  place  after  the  child  has  learnt  to  walk. 

The  rickety  spine  usually  takes  the  form  of  a  general  curve  back- 
wards, i.e.  kyphosis,  affecting  the  whole  dorso-lumbar  region.  In  older 
children,  after  they  have  learnt  to  walk,  the  curvature  may  be  lateral  or  in 
the  form  of  lordosis. 

F(ETAL  ElCKETS,   OSTEO-GENESIS   IMPERFECTA,   ACHONDKO-PLASIA. 

In  rare  cases,  infants  are  born  in  a  condition  which  suggests  that  they 
may  have  suffered  from  rickets  during  foetal  life.  The  limbs  are  stunted, 
the  epiphyses  swollen,  the  shafts  of  the  bones  curved,  the  ribs  are  beaded, 
and  the  chest  misshapen  as  in  rickets.  There  are  often  numerous  fractures 
affecting  the  long,  but  also  the  scapulas  and  other  flat  bones.  Such  children 
either  are  born  dead  or  only  survive  their  birth  a  short  time.  In  a  few  of 
the  cases,  competent  observers  (Barling,  Eotch)  have  described  them  as 
true  rickets,  which  has  taken  place  during  intra-uterine  life.  In  other 
cases  the  resemblance  to  rickets  has  been  more  apparent  than  real ;  in  some 
of  these  there  is  a  pug  nose,  broad  head,  and  extremely  stunted  limbs,  the 
latter  being  often  only  half  their  normal  length.  In  such  cases  there  has 
been  an  arrest  of  development  during  intra-uterine  life  of  cartilaginous  and 
perhaps  also  membranous  ossification.  Most  of  such  cases  are  premature 
or  still-born  ;  a  very  few  survive  their  birth,  and  grow  up  as  dwarfs.  The 
term  achondro-plasia  (Porak,  J.  Thomson)  has  been  applied  to  this  group. 
It  is  safe  to  say  that  many  more  observations  are  required  before  any 
very  dogmatic  statements  can  be  made  respecting  the.se  cases  ;  for  this 
reason  they  are  perhaps  best  classed  under  the  term  of  osteo-genesis  im- 
perfecta, which  leaves  the  question  of  their  nature  an  open  one  (Ballan- 
tyne). 

Late  Kickets. 

Typical  rickets,  such  as  has  been  described  in  this  article,  only  occurs 
during  the  first  two,  or  at  most  three,  years  of  life.  Later  than  this  period, 
when  the  parietal  and  occipital  bones,  epiphyses  of  the  wrist,  and  other 
bones  have  undergone  more  complete  ossification,  the  typical  deformities 
of  early  rickets  do  not  take  place. 


KICKJlTS.  499 

It  is  the  universal  experience  that  the  changes  which  lead  to  the  altera- 
tion in  the  shape  of  the  head,  beading  of  the  ribs,  rickety  deformity  of  the 
chest,  and  bow  legs,  only  occur  at  one  period  of  life,  namely,  during  the 
first  two,  or  at  most  three,  years.  ■ 

It  is,  however,  a  common  experience  that  older  children,  youths,  and 
young  adults,  who  have  never  suffered  from  rickets  during  the  first  year 
or  two  of  their  lives,  do,  after  a  more  or  less  prolonged  period  of  ill-health, 
exhibit  symptoms,  especially  in  connection  with  their  muscles  and  liga- 
ments, which  suggest  rickets.  It  has  been  said  that  these  are  cases  of 
"  relapsed  rickets  "  rather  than  "  late  rickets,"  and  this  may  be  true  of  a 
certain  number  of  cases,  but  it  is  pretty  certain  it  is  not  true  of  all. 
Whichever  view  we  take,  it  is  clear  that  in  a  number  of  cases  children 
of  three  or  four  years  old  and  upwards,  who  have  hitherto  been  fairly 
healthy,  begin  to  show  such  symptoms  as  profuse  sweating,  muscular  weak- 
ness, laxity  of  ligaments,  overgrowth  of  bone  at  the  epiphyses  of  the  ankles 
and  bones  forming  the  knee-joints,  resulting  in  more  or  less  knock-knees, 
flat  feet,  and  perhaps  lateral  curvature  of  the  spine.  These  symptoms 
occur  in  rapidly  growing  children,  but  also  in  those  who  are  growing  very 
slowly.  In  some  of  these  cases  albuminuria  occurs,  but  this  is  by  no 
means  constant.  Such  children  are  apt  to  have  an  ungainly  and  awkward- 
looking  walk  and  carriage;  they  throw  their  feet  out  when  they  walk 
or  run,  giving  way  more  or  less  at  the  knees  and  ankles,  and  loll  about, 
drooping  one  or  both  shoulders  from  tiredness  and  weakness  of  the  muscles 
of  the  back. 

Mild  cases  of  this  class  are  common  enough,  while  severe  cases  in 
which  lateral  deformities  of  the  spine  occur  and  bad  knock- knees  are  far 
from  uncommon.  In  rarer  cases  the  child  or  young  adult  is  unable  to 
make  any  exertion,  either  walking  or  even  sitting,  and  lapses  perhaps  for 
years  into  a  complete  invalid,  spending  most  of  his  time  in  bed  or  on 
a  couch. 

Diagnosis. — It  is  not  very  often  that  there  is  much  difficulty  in 
diagnosing  rickets,  and  there  can  be  none  if  beading  of  the  ribs,  enlarge- 
ment of  the  bones  of  the  wrists,  or  the  peculiar  shape  of  the  head,  is 
present,  these  deformities  being  too  obvious  to  be  overlooked.  In  some 
cases,  where  the  muscles  of  the  trunk  and  legs  are  weak  and  the  child  very 
helpless  as  regards  sitting  up  or  standing,  while  there  is  no  marked  swelling 
of  epiphyses  of  the  wrists  or  obvious  square  looking  head,  there  may  be 
some  doubt  as  to  whether  there  is  actual  partial  paralysis  of  the  muscles, 
or  weakness  due  to  rickets.  It  must  be  borne  in  mind  that  beading  of  the 
ribs  is  seldom  absent  in  rickets  under  two  or  three  years  of  age,  and  if 
there  is  a  general  muscular  weakness  with  beading  of  the  ribs,  the  case  is 
almost  certainly  one  of  rickets.  Anterio-polio-myelitis  is  not  likely  to  pro- 
duce a  general  partial  paralysis  of  the  muscles  of  both  legs.  Moreover,  there 
would  be  wasting  and  the  reaction  of  degeneration  present.  In  some  cases  the 
muscular  weakness  of  rickets  will — in  a  child  who  is  able  to  walk — pro- 
duce symptoms  suggestive  of  an  early  or  slight  case  of  pseudo-hypertrophic 
paralysis.  There  is  not  likely  to  be  any  enlargement  of  the  calf  muscles, 
but  the  difficulty  of  rising  from  the  floor,  except  with  the  help  of  the  arms, 
suggests  the  more  serious  disease.  The  difficulties  of  diagnosis  in  connection 
with  rickets  are  not  so  much  as  to  whether  the  bone  deformities  due  to 
rickets  are  present  or  absent,  but  to  decide  whether  the  rickets  which  is 
present  is  the  primary  and  essential  feature  of  the  case.  Undoubted  rickets 
is  often  associated  with  gastro-intestinal  indigestion,  bronchial  catarrh, 


5oo  GENERAL  DISEASES. 

anaemia,  imbecility,  eclampsia,  etc.,  but  the  question  as  to  whether  it  is 
primary  or  secondary  is  frequently  a  difficult  one.  Has  the  gastric 
catarrh  or  chronic  bronchial  catarrh  present  in  an  infant  directly  or 
indirectly  caused  the  rickets  ?  Or  has  rickets  predisposed  to  gastric  and 
bronchial  catarrh  ?  These  questions  do  not  always  admit  of  a  definite 
answer;  possibly  both  questions  may  be  answered  in  the  affirmative. 
Eickets  unquestionably  predisposes  to  eclampsia  and  also  anaemia,  but  in 
a  given  case  there  may  be  some  other  factor  causing  the  eclampsia  and  the 
anaemia,  and  the  rickets  may  be  only  secondary.  In  these  cases,  if  the 
bone  deformities  are  slight,  rickets  is  hardly  likely  to  be  the  essential 
cause.  Imbecile  and  feeble-minded  children  may  be  rickety,  but  while 
severe  cases  of  rickets  are  often  mentally  backward,  the  presence  of 
rickets  will  not  account  for  idiocy  or  imbecility.  The  hydrocephalic  head 
of  the  infant  ought  not  to  be  confused  with  the  large  square  head  frequently 
seen  in  rickets.  In  the  former,  the  enlarged  head  is  globular,  the  f ontanelles 
bulging,  the  bones  of  the  skull  thin ;  in  the  latter,  the  head  is  square  and 
flat  at  the  top,  the  frontal  and  parietal  eminences  prominent,  the  edges  of 
the  bones  thickened ;  the  fontanelles  do  not  bulge. 

Treatment. — If  rickets  is  due  to  dietetic  causes,  i.e.  mal-digestion 
and  mal-assimilation  of  food  and  possibly  also  to  the  absorption  of  toxines 
from  the  alimentary  canal,  it  is  clear  that  the  most  important  therapeutative 
measures  will  be  those  which  aim  at  improving  the  digestive  powers  and 
supplying  food  of  suitable  quality  and  in  suitable  quantity.  In  any  case 
in  which  the  early  symptoms  of  the  disease,  such  as  sweating,  restlessness, 
prominent  abdomen,  beaded  ribs,  have  manifested  themselves,  the  diet  and 
general  hygiene  of  the  infant  should  be  carefully  regulated.  It  will  almost 
certainly  be  found  that  there  has  been  chronic  dyspepsia  in  progress  for 
some  time,  that  the  digestive  powers  have  been  seriously  weakened,  and  that 
the  infant  cannot  take  and  digest  the  amount  of  food  which  a  healthy  infant 
can.  The  gastric  and  intestinal  juices  are  weak,  the  bile  is  poor  in  quality, 
the  muscles  of  the  stomach  and  intestines  have  lost  much  of  their  tone,  the 
blood  is  poor  and  watery.  The  digestive  juices  are  weak  because  the 
blood  is  poor  and  thin,  and  the  blood  is  likely  to  remain  poor  if  the 
digestive  powers  are  weak.  It  is  clear,  then,  that  no  rapid  improvement 
can  be  expected,  and  the  digestive  organs  will  have  to  be  gradually 
"  coaxed  back "  to  a  normal  condition.  With  the  early  symptoms  of 
rickets  just  referred  to,  it  will  probably  be  found  that  the  infant's  stools 
are  pale  and  putty-like  and  perhaps  foul  smelling.  Or  they  may  be  pale 
and  dry,  so  much  so  that  they  can  be  broken,  or  they  come  away  in  pieces. 
The  infant  is  probably  taking  far  more  curd  of  milk  than  it  can  digest ;  the 
curd  is  partly  undergoing  decomposition  in  the  alimentary  canal  and  in 
part  being  passed  in  the  stools.  The  almost  total  absence  of  yellow  colour 
in  the  stools  suggests  that  an  insufficiency  of  bile  is  being  secreted,  and 
probably  also  the  digestive  juices  are  weak ;  the  peristalsis  of  the  bowels  is 
very  inefficiently  performed.  Possibly  with  this  state  of  things  we  find 
that  the  infant  has  suffered  a  good  deal  and  is  suffering  from  bronchial 
catarrh,  or  it  has  more  or  less  "  child  crowing,"  and  as  a  result  it  is  care- 
fully kept  day  after  day  in  a  close  apartment,  without  fresh  air,  and 
perhaps  a  steam-kettle  constantly  puffing  wet  steam  into  the  room.  The 
indications  for  treatment  will  naturally  be  to  find  a  food  which  the  infant 
can  digest,  which  contains  the  necessary  proteids,  fat,  etc.,  and  at  the  same 
time  to  ensure  that  the  infant  gets  an  amount  of  fresh  air  and  sunlight 
which  is  as  necessary  to  it  as  its  food  and  drink.    With  regard  to  food,  each 


RICKETS.  501 

case  will  have  to  be  treated  on  its  merits,  and  carefully  watched  to  see  how 
digestion  proceeds.  Avoid  a  one-sided  diet.  The  diet  should  contain 
proteids,  fats,  sugars,  salts,  and  there  is  no  harm  in  starches  in  small 
quantities,  if  the  infant,  as  it  probably  will  be,  is  over  8  or  9  months  old. 
Prefer  fresh  food  to  preserved  food  as  far  as  possible,  at  any  rate  make  sure 
there  is  a  sufficiency  of  fresh  food  in  its  diet,  or  scurvy  is  very  likely  to  be 
set  up.  Whey  made  with  Benger's  rennet,  to  which,  after  scalding,  a  fourth 
part  milk  or  a  smaller  quantity  of  fresh  cream  is  added,  may  be  given.  If 
with  this  the  stools  are  pale  and  contain  curd,  raw  beef  juice  may  be  added 
in  place  of  milk.  A  little  thin  and  well-boiled  oatmeal  made  with  whey 
or  milk  and  water  may  be  given,  with  or  without  the  addition  of  malt 
extract  before  being  taken.  No  thick  foods  are  permissible  before  the  age 
of  a  year.  Plasmon  dissolved  in  barley  water  or  whey  is  certainly  of  use 
in  some  cases  for  supplying  proteid  ;  if  given  in  barley  water  it  will  be  well 
to  give  some  orange  juice  daily,  and,  indeed,  this  may  be  given  in  all  cases 
of  rickets,  especially  when  it  has  become  necessary  to  reduce  the  quantity 
of  milk.  Where  milk  laboratories  are  available,  a  milk  food  may  be  ordered 
with  the  proteid  kept  low  at  first,  0-75  to  1*5  per  cent.,  fat  in  moderately 
large  amounts,  3  to  4  per  cent.,  and  sugar,  5  to  6  per  cent.  The  amount 
to  be  taken  to  be  35  to  40  oz.  in  the  twenty-four  hours.  To  attain  much 
success  in  the  treatment  of  such  a  case,  very  careful  watching  is  necessary. 
It  may  be  necessary  from  time  to  time  to  cut  down  the  strength  of  the 
food  or  to  gradually  increase  it. 

The  diet  of  older  children,  say  18  months  to  2  or  2|-  years,  must  be 
managed  in  a  similar  way.  Watch  the  stools.  It  is  quite  certain  if  the 
stools  are  putty -like  and  foul,  the  child  is  not  doing  well.  Eeduce  the 
curd  the  child  is  taking  by  giving  whey,  and  substituting  beef -tea,  chicken 
tea,  raw  beef,  etc.,  for  some  of  the  milk.  Thin  well-boiled  oatmeal  porridge 
and  cream,  yolk  of  egg,  slackly  boiled,  on  sopped  toast,  sandwiches  made 
with  thin  bread  and  butter  and  egg  or  underdone  beef,  or  bone  marrow 
may  be  given  in  small  quantities.  Scraped  raw  beef  or  underdone  beef  is 
of  undoubted  value  in  rickets,  but  the  quality  of  the  beef  requires  most 
careful  supervising,  as  the  risk  of  the  child  becoming  the  host  of  a  tape- 
worm is  by  no  means  small  if  there  is  any  carelessness  in  the  selection  of 
the  meat.  Proteids  and  fats  the  child  undoubtedly  requires,  but  milk  is 
apt  to  disagree  in  many  cases  of  rickets,  and  the  difficulty  often  consists  in 
finding  suitable  and  easily  digested  proteids.  An  excess  of  curd  of  milk 
given  may  mean  not  only  proteid-starvation  but  toxine-poisoning. 

The  importance  of  fresh  air  in  the  treatment  of  rickets  cannot  be  over- 
estimated, it  is  just  as  important  in  this  disease  as  in  the  treatment 
of  tuberculosis.  The  worst  cases  to  treat  are  those  who  are  subject  to 
bronchial  catarrh,  especially  during  the  winter  months.  The  treatment  of 
rickets  is  mostly  unsatisfactory  in  hospital,  unless  there  is  opportunity  of 
sending  the  infants  daily  into  the  open  air.  Whenever  it  is  possible  and 
the  weather  is  fit,  let  the  infant  spend  the  whole  day  in  the  open  air,  and 
take  its  meals  outside.  During  the  six  months  of  winter,  a  seaside  place 
with  a  sandy  shore,  and  where  shelter  from  high  winds  can  be  obtained,  is 
far  more  suitable  for  a  rickety  infant  than  a  city  or  inland  resort.  Great 
care  must  naturally  be  taken  not  to  over-expose  the  rickety  infant,  who 
easily  gets  bronchial  catarrh,  but  too  much  coddling  is  bad,  and  renders  the 
infant  too  much  of  a  hot-house  plant,  and  too  sensitive  to  outside  air.  Use 
them  gradually  to  fresh  air,  by  admitting  the  air  to  the  bedrooms,  when 
the  infant  is  suitably  dressed. 


502  GENERAL  DISEASES. 

It  is  of  course  necessary  to  very  carefully  attend  to  the  clothing  of  sen- 
sitive children.  Shetland  wool  vests,  abdominal  belts  of  the  same  material^ 
woollen  or  flannel  outer  clothing,  gamgee  tissue  napkins,  and  suitable  wraps 
when  the  infant  goes  out.  Keep  the  feet  warm  with  a  hot-water  bottle  at 
the  foot  of  the  carriage  when  the  child  goes  out  in  cold  weather.  In  severe 
cases  the  most  careful  handling  is  necessary,  as  fractures  easily  take  place,, 
and  the  prone  position  on  a  soft  mattress  or  cushion  in  the  cot  or  carriage 
is  better  than  much  nursing  in  the  arms  or  sitting  up  in  a  chair,  on  account 
of  weakness  of  the  back.  Much  difficulty  is  experienced  in  keeping  the 
child  off  its  feet  or  attempting  to  stand  or  crawl,  whilst  the  bones  of  the 
legs  are  still  more  or  less  soft  and  the  ligaments  of  the  joints  weak.  Such 
children  want  amusing  during  their  waking  hours,  and  much  ingenuity  and 
patience  must  often  be  exercised  to  keep  them  off  their  feet. 

Of  medicines  the  most  important  are  those  which  assist  digestion  or 
overcome  faulty  conditions  of  the  mucous  membrane  of  the  stomach  and 
bowels.  The  troublesome  constipation  also  requires  attention.  From  time 
to  time  a  dose  of  calomel  (|-  to  1  gr.)  is  useful  to  carry  away  accumulations 
of  decomposing  and  fermenting  food.  Acids  and  pepsin  are  useful  in  many 
cases — Acid,  nitrici  dil.,  1  minim ;  liq.  pepsin  and  euonymin,  20  minims ; 
aq.  lauro-cerasi,  5  minims ;  sp.  chloroformi,  1  minim ;  aq.  aurantii  flor.  ad 
1  dr.     1  dr.  t.d.s. — Infant  8  months  to  18  months. 

If  there  is  constipation  and  much  gaseous  distension  of  the  abdomen, 
soda  and  rhubarb  is  often  of  value,  given  in  small  and  repeated  doses  for  a 
week  or  two — Sod.  bicarb.,  2  gr. ;  pulv.  rhei,  %—:, \  gr. ;  sp.  chloroformi,  1 
minim ;  syrup,  pruni  virgin.,  15  minims ;  aq.  ad  1  dr.  1  dr.  t.d.s. — Infant,, 
to  18  months. 

Glycerin  or  oil  enemas  may  be  necessary  from  time  to  time  to  get  the 
bowels  to  act.  Cod-liver  oil  is  of  undoubted  service,  especially  in  the  form 
of  emulsion,  where  the  digestive  organs  are  comparatively  healthy ;  it  is 
better  not  given  if  there  is  much  dyspepsia.  Iron  and  arsenic  are  of  some 
value  in  the  anaemic  cases,  the  former  as  iron-somatose  or  Hommel's  hsema- 
togen,  and  the  latter  in  the  form  of  Levico  water.  Phosphorus  has  been 
vaunted  as  a  specific  ;  it  is  however,  very  little  used  at  the  present  time,  and 
has  deservedly  fallen  into  disrepute. 

Cases  of  laryngismus  are  often  troublesome,  and  it  may  be  some  weeks 
or  even  months  before  the  tendency  to  laryngeal  spasm  and  convulsions 
is  overcome.  The  most  important  matter  to  be  attended  to  is  the  diet,  for 
it  is  almost  certain  to  be  at  fault.  Then  fresh  air,  preferably  seaside,  is 
of  the  greatest  importance ;  but  as  sudden  death  from  spasm  of  the  glottis 
takes  place  at  times,  it  may  not  be  always  wise  to  send  them  away  from 
home  to  the  seaside.  Calomel  and  phenacetin  (aa  1  gr.)  may  be  given  to 
clear  out  the  bowels,  the  latter  given  as  a  nerve  sedative.  Bromide  and 
rhubarb  may  be  given — pot.  bromid.,  2|-  gr.;  pulv.  rhei,  \  gr.;  sp.  chloroformi, 
1  minim ;  syrup,  aurant.,  20  minims ;  aq.  ad  1  dr.  1  dr.  t.d.s. — Infant  8 
months  to  1  year.)  Perhaps  the  best  antispasmodic  in  severe  cases  is 
morphine  given  subcutaneously  in  y^-g-  to  TV  gr.  doses,  or  chloral  hydrate 
given  in  doses  of  2  or  3  gr. — Infant  8  months  to  2  years. 

The  treatment  of  rickety  deformities  mostly  falls  to  the  surgeon,  and 
splints  or  osteotomies  may  be  required,  but  a  good  deal  can  be  done  to 
improve  the  muscular  power  by  massage  and  baths,  and  by  daily  gentle 
manipulation  to  straighten  curved  tibiae,  if  it  is  persistently  practised 
before  the  bones  have  become  firmly  set  in  a  faulty  position. 

The  treatment  of  rickets  does  not  consist  in  prescribing  "  chemical 


FRAG  I  LIT  AS  OSSIUM.  503 

food  "  or  cod-liver  oil,  but  in  carefully  studying  the  digestive  powers  of  the 
individual  infant  and  giving  it  a  generous  supply  of  fresh  air. 

HENRY   ASHBY. 


FRAGILITAS  OSSIUM. 


Fragilitas  ossium  signifies  an  abnormal  brittleness  of  the  bones;  it  is 
applied  to  cases  in  which  fractures  take  place  as  the  result  of  slight 
accidents  or  muscular  action.  The  term  is  applied  to  two  fairly  distinct 
classes  of  cases — (1)  A  rare  condition,  in  which  brittleness  of  the  bones 
exists,  unconnected  with  any  other  well-known  disease ;  usually  the  subjects 
are  in  good  health.  (2)  An  abnormal  brittleness  of  the  bones,  which  is  the 
result  of  some  disease,  as  rickets  or  scurvy. 

Etiology. — The  idiopathic  form  is  in  some  cases  hereditary,  and 
several  members  of  the  same  family  may  be  affected;  there  is  a  family 
tendency  to  fractures,  which  may  be  comparatively  slight  or  very  un- 
mistakable. Greenish  records  a  remarkable  instance  of  this  hereditary 
tendency  to  fracture.  The  grandfather  of  the  family  was  an  invalid,  from 
numerous  fractures.  Of  his  three  sons,  one  had  one  fracture ;  and  of  this 
son's  children,  one  had  thirteen  and  another  two.  The  second  son  had  two 
fractures ;  and  of  his  children,  one  had  eight,  three  had  four  each,  and  one 
had  three.     The  third  son  and  two  daughters  had  no  fractures. 

Disease  of  limbs,  as  from  lying  in  bed  for  many  months,  is  apt  to  lead 
to  atrophy  of  bone  and  consequent  brittleness.  The  ease  with  which  the 
bones  of  lunatics  fracture  is  well  known ;  doubtless  in  these  cases  atrophy 
of  bone  occurs. 

It  is  an  important  fact,  first  pointed  out  by  Magitot,  that  workers  in 
match  factories,  where  yellow  phosphorus  is  used,  seem  abnormally  liable 
to  fractures  of  their  long  bones.  Cases  have  been  reported  by  Gorman  and 
Dearden  in  this  country,  and  by  several  Continental  writers. 

In  the  secondary  form  the  fragility  of  the  bones  is  obviously  the 
result  of  some  diseased  or  morbid  condition ;  thus,  for  instance,  it  occurs  in 
malignant  tumours  of  bone,  rickets,  scurvy,  purpura,  atrophy  of  bone, 
osteo-malacia,  phosphorus  poisoning. 

Symptoms. — The  first  fracture  usually  occurs  during  early  life, 
perhaps  about  or  before  puberty ;  boys  appear  to  suffer  much  more  than 
girls.  The  bone  perhaps  breaks  with  ridiculous  ease,  as  for  instance  a 
fracture  of  the  humerus  occurs  when  in  the  act  of  throwing  a  cricket  ball, 
or  a  leg  is  twisted,  and  the  femur  snaps.  There  is  no  bending  of  the  bone 
as  in  osteo-malacia,  and  no  greenstick  fracture.  Union  takes  place  usually 
without  any  difficulty,  though  exceptions  to  this  have  been  reported.  As 
the  individual  gets  older,  other  fractures  of  the  bones  of  the  leg  or  arm, 
clavicle  or  ribs,  occur,  and  deformity  of  the  limbs  may  take  place  in  conse- 
quence. The  individuals  appear  to  enjoy  good  health.  The  cause  is  unknown, 
and  examination  of  the  bones  has  not  thrown  any  light  on  the  subject. 

Infants  occasionally  suffer  fracture  of  their  bones  during  parturition  or 
during  intra-uterine  life.  In  some  of  these  cases  there  is  evidently  disease 
of  the  bones  (see  "  Foetal  Eickets,"  p.  498).  In  others  there  is  no  obvious 
disease  to  be  made  out.  Thus  in  an  infant  2  weeks  old,  admitted  into  the 
Manchester  Children's  Hospital,  both  humeri  and  one  femur  had  been 
fractured   during  labour.     Splints  were  applied,  and  union  took  place ; 


504  GENERAL  DISEASES. 

during  its  stay  in  the  hospital  the  other  femur  fractured  in  the  middle 
third,  without  any  obvious  violence  or  accident.  The  infant  seemed 
healthy;  there  were  no  enlarged  epiphyses,  but  the  ribs  were  slightly 
beaded,  and  the  occipital  bone  flattened  from  lying  on  its  back. 

Diagnosis. — In  rickets  the  fracture  is  usually  of  the  greenstick 
variety ;  in  scurvy  it  is  usually  a  separation  of  the  epiphysis,  especially  at 
the  lower  end  of  the  femur.  In  one  case,  seen  by  the  writer,  this  latter 
accident  occurred  while  the  infant  (11  months)  was  being  bathed.  In 
another  case  of  a  child  of  14  months,  suffering  from  anaemia,  and  both 
rickets  and  scurvy,  fractures  of  both  humeri  took  place ;  the  fractures  were 
oblique  and  complete,  there  was  much  effusion  of  blood  beneath  the 
periosteum ;  this  was  verified  at  the  post-mortem,  death  taking  place  a 
few  weeks  after  the  accident.  The  fractures  had  apparently  occurred  as 
the  result  of  holding  both  arms  of  the  child,  and  shaking  it  to  stop  its 
crying.  In  some  cases  of  ansemia  and  purpura  with  malnutrition  in  older 
children,  the  bones  become  brittle  and  readily  break.  The  writer  has 
made  more  than  one  post-mortem  examination  of  children  in  whom  there 
were  bruise  marks,  internal  haemorrhages,  and  multiple  fractures,  which 
suggested  cruelty  on  the  part  of  the  parents ;  but  an  examination  showed 
the  bones,  especially  the  ribs,  were  soft  and  readily  broken  by  slight 
violence. 

HEj^EY  ASHBY. 


OSTEO-MALACIA— MOLLITIES  OSSIUM. 

Osteo-malacia,  as  the  name  implies,  signifies  softening  of  the  bones.  In 
typical  cases  it  is  a  well-defined  disease,  but  in  some  other  cases,  in  which 
more  or  less  decalcification  of  bones  occurs  in  early  life,  there  is  a 
difficulty  in  deciding  whether  to  include  them  under  the  term  osteo- 
malacia or  not. 

Etiology  and  morbid  anatomy. — In  typical  cases  the  disease 
occurs  in  women — men  but  rarely — between  the  ages  of  25  and  35; 
pregnancy  seems  to  be  an  exciting  cause. 

The  bones  are  the  only  part  of  the  body  that  appear  to  be  affected. 
The  early  stages  of  the  disease  appear  to  consist  in  a  gradual  decalcification 
of  the  bones,  leaving  the  animal  matter  intact.  Later,  the  decalcified  bone 
is  gradually  converted  into  a  grumous  blood-stained  jelly,  with  perhaps 
some  thin  layer  of  firmer  substance  beneath  the  periosteum. 

Symptoms. — Adult  form. — In  the  early  stages,  pains  in  the  bones, 
which  are  assumed  to  be  rheumatic,  are  felt,  but  in  many  cases  the  first 
symptoms  are  those  connected  with  the  bending  of  the  long  bones  or  pelvis. 
Frequently  the  first  bone  to  be  affected  is  the  pelvis,  the  deformed  pelvis 
being  discovered  per  vaginam  by  the  accoucheur ;  the  cavity  of  the  pelvis  is 
narrowed  by  the  sides  falling  in  and  the  sacrum  being  thrust  forward. 
The  deformity  may  be  confined  to  the  pelvis ;  usually  other  bones  are  also 
affected.  It  may  be  noticed  that  the  stature  is  diminished,  in  consequence 
of  the  femurs  bending ;  or  the  bones  of  the  arms  can  be  bent  by  manipu- 
lation into  all  sorts  of  curves,  or  may  fracture.  The  chest  and  spine  may 
become  deformed. 

The  disease  is  mostly  chronic,  and  goes  on  for  years ;  the  patient  is 
bedridden  and  helpless,  and  perhaps  finally  dies  of  asthenia,  or  in  con- 
sequence of  the  softening  of  the  ribs  preventing  the  expansion  of  the  chest. 


DIABETES  MELLITUS.  505 

Juvenile  form. — While  the  diagnosis  in  cases  just  descrihed  cannot  be 
difficult,  there  is  a  great  deal  of  uncertainty  with  regard  to  certain  cases  of 
bone  softening  which  occur  during  early  life.  In  some  cases  of  newly  born 
infants,  the  bones  readily  bend,  in  consequence  of  a  deficiency  of  mineral 
matter,  without,  at  the  same  time,  there  being  any  epiphyseal  over-growth, 
as  in  rickets.  Judson  Bury  records  a  case  of  an  infant  born  with  bent 
limbs,  which  died  when  8  months  old.  At  the  post-mortem  examination, 
it  was  found  that  the  bones  could  be  bent  with  the  greatest  ease,  and  it 
required  great  care  to  remove  a  rib  without  breaking  it ;  the  tibia  and 
other  bones  were  easily  cut  with  a  knife,  and  consisted  of  a  mere  shell  of 
bone  beneath  the  periosteum,  while  the  interior  of  the  shaft  was  filled  with 
soft  pulpy  tissue.  There  were  no  enlarged  epiphyses  or  evidence  of  rickets. 
Similar  cases  occur  both  in  infants  and  young  adults. 

Treatment. — No  known  remedy  appears  to  have  any  influence  over 
the  disease.     The  treatment  is  that  of  symptoms. 

HENRY  ASHBY. 


DIABETES  MELLITUS 


Diabetes  MELLITUS  is  a  disease  in  which  there  is  persistent  excretion  of 
grape  sugar  in  the  urine.  The  term  glycosuria  is  usually  applied  to  the 
condition  in  which  there  is  a  temporary  excretion  of  grape  sugar  in  the 
urine ;  and  in  such  cases  the  sugar  excretion  is  usually  small.  But  some 
writers  also  apply  the  term  chronic  glycosuria  to  the  mild  cases  of  per- 
sistent sugar  excretion  (mild  forms  of  diabetes  mellitus),  and  reserve  the 
term  diabetes  for  the  severe  forms. 

Physiological  considerations. — The  carbohydrate  products  of 
digestion  are  conveyed  to  the  liver,  and  this  organ  contains  glycogen, 
which  is  present  in  greatest  quantity  when  a  carbohydrate  diet  is  taken. 
It  is  still  a  disputed  point  whether  the  function  of  the  liver  is  to  con- 
stantly pay  out  small  quantities  of  sugar  into  the  general  circulation, 
or  whether  the  liver  and  intestinal  villi  act  in  the  opposite  manner  and 
prevent  sugar  entering  the  general  circulation,  as  Pavy  suggests.  If,  in 
the  normal  condition,  sugar  were  constantly  passing  into  the  general 
circulation  from  the  liver,  Pavy  thinks  that  it  would  be  detected  in 
quantity  in  the  urine :  he  believes  that  any  excess  of  sugar  in  the  blood 
is  eliminated  by  the  kidneys.  But  whatever  the  function  of  the  liver  may 
be,  the  blood  does  contain  a  very  small  quantity  of  sugar.  Minkowski  has 
shown  that  excision  of  the  liver  causes  the  sugar  in  the  blood  to  disappear ; 
and  the  same  result  has  been  obtained  by  ligature  of  the  blood  vessels  of 
the  liver  (Bock,  Hoffmann,  Seegen).  Glycosuria  was  not  produced  by  the 
intravenous  injection  of  large  quantities  of  sugar  in  the  experiments  of 
Biedl  and  Kraus.  Also  glycosuria  was  not  produced  by  the  subcutaneous 
injection  of  dextrose,  laevulose,  and  galactose  in  the  experiments  of  Voit ; 
but  after  the  injection  of  cane  and  milk  sugar  the  whole  of  these  substances 
were  excreted  in  the  urine. 

Experimental  diabetes  and  glycosuria. — Diabetes  or  glycosuria  has 
been  produced  in  animals  by  experimental  lesions  of  various  parts  of  the 
nervous  system:  puncture  of  the  floor  of  the  fourth  ventricle  (Claude 
Bernard),  division  of  the  medulla  (Pavy),  injury  of  the  vermiform  process 
of  the  cerebellum  (Eckhard),  injury  of  the  pons  and  posterior  columns  of  the 


506  GENERAL  DISEASES. 

spinal  cord  (Sckiff),  centrifugal  vagus  irritation  (Arthand  and  Butte). 
By  the  injection  of  defibrinated  arterial  blood  into  the  portal  vein,  diabetes 
was  produced  by  Pavy. 

It  has  been  shown  by  Minkowski  and  v.  Mering,  de  Dominicis,  and 
others,  that  total  extirpation  of  the  pancreas  in  animals  is  followed  by 
diabetes  mellitus.  If  a  portion  of  the  pancreas  (|  to  A)  be  left  in  the 
abdomen,  diabetes  does  not  occur.  Also  Minkowski  has  shown  that  a 
portion  of  pancreas,  grafted  under  the  skin  of  the  abdominal  wall,  will 
prevent  the  occurrence  of  diabetes,  when  the  whole  of  the  gland  is  removed 
from  the  interior  of  the  abdomen ;  but  if  this  graft  be  subsequently 
excised,  then  diabetes  is  produced.  It  appears  probable  that  in  the  normal 
condition  an  "  internal  secretion  "  is  absorbed  from  the  pancreas,  which  has 
a  sugar-destroying  action  (Lepine). 

Glycosuria. — In  addition  to  true  diabetes,  or  permanent  glycosuria, 
cases  are  often  met  with  in  which  sugar  is  present  in  the  urine  for  a  short 
time  only — temporary  glcosuria. 

In  health,  the  power  of  sugar-destruction  in  the  system  is  not  un- 
limited, and  if  very  large  quantities  of  sugar  be  taken,  slight  glycosuria 
occurs.  According  to  v.  Noorden,  150-200  grms.  of  cane  sugar,  180-250 
of  grape  sugar,  or  120  of  milk  sugar,  when  given  in  one  quantity  on  an 
empty  stomach,  will  cause  sugar  to  appear  in  the  urine  in  a  healthy 
person.  In  various  diseases,  and  in  apparently  healthy  persons,  the 
power  of  sugar-destruction  is  sometimes  much  diminished.  This  has  been 
noted  in  some  cases  of  Graves's  disease,  cirrhosis  of  the  liver,  chronic 
alcoholism,  obesity,  etc. 

As  a  test  for  diminution  of  the  power  of  sugar-destruction,  100  grms.  of 
dextrose  may  be  given  two  hours  after  a  breakfast  of  coffee  and  bread.  If 
a  decided  reaction  for  sugar  is  obtained 'afterwards  in  the  urine,  the  sugar- 
destroying  power  of  the  system  is  diminished  (Naunyn). 

It  has  been  shown  that  in  the  puerperal  state,  milk  sugar  (lactose)  is 
usually  present  in  the  urine  at  some  period.  Glycosuria,  with  increase  in 
the  quantity  and  specific  gravity  of  the  urine,  may  be  produced,  both  in 
man  and  in  animals,  by  the  administration  of  phloridzin  by  mouth  or 
hypodermically  (phloridzin  diabetes).  Other  substances  sometimes  pro- 
duce slight  glycosuria  when  taken  in  toxic  doses ;  for  example,  opium, 
chloral,  hydrocyanic  acid,  arsenic,  phosphorus,  uranium  salts,  etc. ;  chloro- 
form and  ether  narcosis  also  occasionally,  but  not  invariably,  produce 
slight  temporary  glycosuria. 

Slight  glycosuria  occurs  sometimes  after  injuries  to  the  head  and 
fractures  of  the  skull;  it  is  occasionally,  though  very  rarely,  associated 
with  brain  affections,  such  as  cerebral  haemorrhage,  meningitis,  tumour  of 
the  brain  (exceedingly  rare),  or,  in  very  rare  instances,  with  other  diseases 
of  the  nervous  system,  such  as  disseminated  sclerosis,  locomotor  ataxia,  or 
Graves's  disease.  Occasionally  it  occurs  for  a  short  period  after  various 
fevers — typhoid,  scarlet  fever,  and  diphtheria.  A  few  cases  are  on  record 
in  which  pentose  has  been  present  in  the  urine,  and  has  given  rise  to  a 
reduction  of  Fehling's  solution,  but  no  definite  symptoms  have  been 
observed  in  these  cases. 

Etiology. — Diabetes  is  not  a  common  disease.  At  the  Manchester 
Eoyal  Infirmary  in  twenty  years  there  were  272  diabetic  cases  amongst 
27,721  medical  in-patients,  i.e.  0*9  per  cent.  In  England,  France, 
Denmark,  and  the  United  States,  the  mortality  from  diabetes  is  steadily 
increasing.     The  German  view  is  especially  prone  to  diabetes.     In  India, 


DIABETES  MELLITUS.  507 

chiefly  amongst  the  Hindus,  in  Ceylon,  South  Italy,  and  Malta,  the  disease 
is  met  with  more  frequently  than  in  other  countries. 

The  disease  is  more  frequent  in  males  than  females.  It  is  more  common 
in  adults,  though  cases  are  met  with  in  young  persons  and  children.  The 
death-rate  from  diabetes  is  greatest  after  40. 

Predisposing  and  exciting  causes. — There  are  a  number  of  predis- 
posing or  exciting  causes  which  sometimes  appear  to  play  a  part  in 
determining  the  onset  of  the  disease,  though  it  is  probable  that  there  is 
always  some  additional  unknown  factor  in  the  causation.  The  following 
are  the  more  important;  and  the  percentages  amongst  100  diabetic  patients 
examined  by  the  writer,  in  which  there  was  a  history  of  these  predisposing 
or  exciting  causes,  is  given  in  brackets. 

A  family  history  of  the  disease  is  sometimes  obtained.  A  brother  or 
sister  may  have  been  diabetic  also ;  sometimes  an  uncle  or  aunt ;  very 
rarely  has  the  father  or  mother  suffered.  In  13  per  cent,  of  the  writer's  cases 
a  family  history  was  obtained.  In  one  instance  two  brothers  and  a  sister 
died  of  diabetes;  in  another,  three  sisters  suffered  from  it.  A  severe 
external  injury,  usually  of  the  head,  has  been  the  exciting  cause  in  a  few 
cases,  6  per  cent..  Many  instances  are  on  record  in  which  the  disease 
has  rapidly  followed  fright,  violent  passion,  strong  mental  emotions,  mental 
anxiety  and  worry,  10  per  cent.  Mental  anxiety  and  over- work,  con- 
nected with  the  nursing  of  a  sick  relative,  appears  sometimes  to  be  an 
exciting  cause,  8  per  cent.  Alcoholism — usually  excessive  beer-drinking — 
probably  predisposes  to  the  disease,  17  per  cent.  Diabetes  has  occa- 
sionally developed  directly  after  an  acute  illness,  such  as  influenza,  8  per 
cent. ;  acute  fevers,  pneumonia,  bronchitis,  pleurisy,  after  exposure  to 
wet  and  cold,  after  the  taking  of  a  large  quantity  of  cold  fluid  when  the 
body  has  been  very  hot.  Possibly  syphilis  may  be  occasionally  an  indirect 
cause  of  diabetes,  by  producing  cerebral  or  pancreatic  lesions.  In  cases  of 
acromegaly,  diabetes  or  glycosuria  often  develops.  Occasionally  diabetes 
commences  during  pregnancy,  6  per  cent.  It  has  been  suggested  that 
the  climacteric  period  predisposes  to  the  development  of  diabetes  in 
women.  Mild  forms  of  diabetes  are  sometimes  associated  with  gout 
or  obesity,  4  per  cent.,  especially  in  elderly  persons.  In  young 
persons,  marked  obesity  has  occasionally  preceded  a  severe  form  of 
the  disease.  Often  no  history  of  any  exciting  or  predisposing  cause  can 
be  obtained. 

Pathology. — Diabetes  mellitus  has  no  characteristic  morbid  anatomy. 
Often  the  morbid  anatomical  or  histological  changes  are  slight,  and  due 
only  to  complications ;  but  in  some  cases  changes  are  found  in  the  pancreas 
or  brain  which  are  probably  the  cause  of  the  disease. 

The  condition  of  the  blood  will  be  described  in  the  section  on  symptom- 
atology. The  heart  is  often  small  and  atrophied  in  severe  cases ;  but 
cardiac  hypertrophy  is  sometimes  found.  The  cardiac  muscle  sometimes 
presents  fatty  or  glycogenic  degeneration. 

The  lungs  present  signs  of  tuberculous  phthisis,  early  or  advanced,  in 
about  half  of  the  autopsies  on  diabetic  hospital  patients.  The  lung  affection 
runs  a  rapid  course ;  caseation  soon  occurs,  and  cavities  form ;  there  is  no 
tendency  to  cicatrisation.  Occasionally  chronic  pneumonic  gangrene, 
broncho-  and  croupous  pneumonia,  are  met  with. 

No  important  changes  are  found  in  the  alimentary  canal.  Occasionally 
tuberculous  ulceration  of  the  intestines  has  been  present.  The  liver  is 
often  enlarged,  in  other  cases  normal  or  diminished  in  size.     Congestion, 


508  GENERAL  DISEASES. 

fatty  infiltration,  and  cirrhosis  are  occasionally  found.     Multiple  abscesses 
were  present  in  one  of  the  writer's  cases. 

Changes  are  often  found  in  the  pancreas.     The  condition  of  the  pancreas 
in  twenty-four  cases  examined  by  me  was  as  follows  : — 

Cases, 
(a)  Extensive  changes  (marked  cirrhosis  2,  cancer  1,  very  marked 

atrophy  1)  ......  4 

(&)  Well-marked  changes  (cirrhosis  2,  lipomatosis  1,  atrophy  with 

fatty  degeneration  and  infiltration  1)  .  .  .4 

(c)  Slight  changes  (atrophy  with  fatty  degeneration  1,  atrophy  out 

of  proportion  to  the  general  wasting  2)  .  .3 

(d)  Atrophy,  but  only  corresponding  to  the  general  wasting  .  5 

(e)  ^Normal,  macroscopically  and  microscopically  .  .  .8 

24 

Marked  atrophy  has  often  been  recorded ;  sometimes  the  gland  tissue 
has  been  almost  completely  destroyed  by  cirrhosis  or  by  fatty  degeneration 
and  infiltration  ;  pancreatic  calculi  with  fibroid  change,  and  pancreatic  cysts 
have  been  also  found.  Occasionally  there  has  been  advanced  arterio- 
sclerosis of  the  pancreatic  vessels,  which  has  apparently  been  the  cause  of 
the  pancreatic  changes. 

The  kidneys  are  often  hypertrophied,  in  other  cases  they  are  normal 
macroscopically.  Changes  are  frequently  present  in  the  renal  epithelium  : 
hyaline  degeneration,  necrosis  of  epithelium,  fatty  degeneration,  glycogenic 
degeneration,  chiefly  in  the  loop  of  Henle.  Occasionally  chronic  nephritis 
(parenchymatous  or  interstitial)  is  present  as  a  complication. 

The  brain  is  often  normal,  or  presents  only  changes  which  are  slight  or 
due  to  complications ;  but  sometimes  lesions  are  found  which  are  probably 
the  cause  of  diabetes,  such  as  tumour,  softening,  fatty  degeneration, 
sclerosis,  cysticercus,  etc.,  in  the  floor  of  the  fourth  ventricle ;  tumour  of  the 
medulla'  and  of  the  base  of  the  brain ;  tumour  compressing  the  vagus  nerve. 
In  five  out  of  ten  cases  examined  microscopically  by  the  writer,  there  was 
well-marked  dilatation  of  the  small  blood  vessels  in  the  vagus  nucleus,  but 
in  the  other  five  cases  no  changes  of  importance  were  detected.  Tumour 
of  the  pituitary  body  has  often  caused  diabetes  or  glycosuria,  with  or  with- 
out symptoms  of  acromegaly. 

The  spinal  cord  is  usually  normal,  but  the  writer  has  found  degenerative 
changes  in  the  posterior  columns  in  two  cases,  probably  the  result  of  the 
altered  blood  condition ;  other  similar  cases  have  been  recorded.  In  a 
very  few  cases,  lesions  of  the  cervical  region  of  the  cord  (tumour  or  soften- 
ing) have  been  found,  which  may  have  played  some  part  in  the  causation  of 
the  diabetes. 

Pathogenesis. — There  can  be  no  doubt,  at  least  in  the  majority  of 
cases,  that  sugar  appears  in  the  urine  on  account  of  the  excess  of  sugar  in 
the  blood,  and  the  symptoms  of  the  disease  are  due  to  the  same  cause. 
The  increased  amount  of  sugar  in  the  blood  is  believed  by  some  writers 
to  be  due  to  excessive  sugar  production  in  the  organism ;  by  others,  to  dim- 
inished sugar  destruction,  or  to  diminished  destruction  in  some  cases  and 
increased  production  in  other  cases.  Limited  space  forbids  a  discussion  of 
the  conflicting  views  on  this  subject. 

In  the  mild  forms  the  sugar  in  the  urine  appears  to  be  derived  directly 
or  indirectly  from  the  carbohydrates  of  the  food,  since  a  rigid  diet,  free 
from  those  substances,  causes  the  glycosuria  to  cease.     Seegen  believes  that 


DIABETES  MELLITUS.  509 

in  these  cases  the  liver  cells  are  unable  to  transform  the  carbohydrates 
normally.  According  to  Pavy,  there  are  two  lines  of  defence,  the  cells  of 
the  intestinal  villi  and  the  liver.  If  synthesis  of  the  carbohydrates  derived 
from  the  diet  is  not  performed  at  these  two  defence  lines  in  a  normal 
manner,  sugar  reaches  the  general  circulation  in  abnormal  quantities,  and 
appears  in  the  urine.  In  the  severe  forms  of  the  disease,  however,  the 
sugar  excretion  continues  when  the  diet  is  free  from  carbohydrates,  and 
even  when  no  food  is  taken.  In  these  cases  it  appears  probable  that  sugar 
is  produced  from  the  proteids  of  the  body  (as  suggested  by  Pavy  and 
others). 

Whether  we  accept  the  view  of  increased  sugar  formation,  or  diminished 
sugar  destruction,  as  the  cause  of  the  excess  of  sugar  in  the  blood,  we  have 
still  to  consider  why  this  abnormality  should  occur. 

There  is  strong  evidence  in  favour  of  some  change  in  the  central  nervous 
system  being  the  starting-point  of  the  disease  in  certain  cases.  As  already 
mentioned,  occasionally  the  disease  has  immediately  followed  a  severe 
mental  shock  or  fright.  Experiments  on  animals  have  shown  that  injury  to 
the  floor  of  the  fourth  ventricle,  and  other  parts  of  the  medulla  and  base  of  the 
brain,  will  produce  diabetes  mellitus.  Post-mortem  examination  in  patients 
dying  of  diabetes  has  sometimes  revealed  changes  in  the  floor  of  the  fourth 
ventricle,  in  the  medulla,  or  base  of  the  brain,  as  already  mentioned.  Un- 
doubtedly examination  of  the  nervous  system,  including  microscopical 
examination  of  the  medulla,  reveals  no  very  definite  changes  in  the  majority 
of  cases.  But  it  is  still  possible  that  minute  changes  may  be  sometimes 
present  in  the  nerve  cells  of  the  vagus  nucleus  or  other  parts  of  the  medulla, 
which  cannot  be  recognised  at  present  by  microscopical  examination. 
Pavy  has  suggested  vasomotor  paralysis  and  dilatation  of  the  small  vessels 
of  the  liver  as  the  cause  of  diabetes,  but  this  view  has  been  criticised  by 
Seegen. 

Experiments  on  animals  show,  as  already  mentioned,  that  total  extirpa- 
tion of  the  pancreas  produces  diabetes.  Post-mortem  examination  of 
diabetic  patients  has  often  revealed  extensive  changes  in  the  pancreas  ;  and 
there  can  be  little  doubt  that  these  changes  have  been  the  cause  of  the 
disease,  when  there  has  been  very  marked  destruction  of  the  pancreatic 
tissue  (as  in  group  (a)  of  twenty-four  cases  tabulated).  But  in  other 
cases  the  pancreas  is  normal  macroscopically  and  microscopically  (eight 
of  the  twenty-four  cases  tabulated),  and  in  such  cases  diabetes  has  been  due 
to  lesion  of  other  parts,  or,  if  due  to  pancreatic  affection,  the  disease  must 
have  been  a  functional  one,  giving  rise  to  no  histological  changes. 

Probably  atheroma  is  the  cause  of  a  few  cases  of  diabetes,  by  producing 
marked  disease  of  the  pancreatic  vessels  and  consequent  extensive  fatty  or 
fibrous  changes  in  the  pancreatic  tissue.  The  changes  which  are  found  in 
the  liver  cannot,  in  the  majority  of  cases,  be  regarded  as  playing  any  part 
in  the  causation  of  the  disease,  since  similar  changes  are  so  frequently  met 
with  when  there  have  been  no  symptoms  of  diabetes  during  life.  Bunge 
and  others  have  suggested  that  diabetes  may  be  the  result  of  some 
pathological  chemical  changes  occurring  in  the  muscles  in  certain  cases. 

It  appears  probable  that  the  starting-point  of  the  disease  is  not  always 
the  same.  In  many  cases  there  is  no  history  of  any  exciting  cause,  and  the 
pathological  examination  fails  to  reveal  any  lesion  in  the  brain,  pancreas, 
liver,  or  other  parts  to  which  the  disease  can  be  attributed. 

Symptoms. — Onset. — The  first  signs  of  the  disease  are  usually 
thirst  and  diuresis,  sometimes  cramps  in  the  calf  muscles  at  night :  or 


5io  GENERAL  DISEASES. 

the  patient  may  seek  medical  advice  on  account  of  weakness  and  loss  of 
flesh,  or  on  account  of  one  of  the  complications  (eczema  of  the  genital 
organs,  gangrene,  carbuncle,  cataract,  etc.).  Apparently  the  thirst  occa- 
sionally commences  very  suddenly.  Sometimes  very  slight  glycosuria  has 
been  detected  months  or  years  before  the  onset  of  true  diabetes. 

External  appearance. — In  severe  forms  the  face  is  often  wasted, 
the  wrinkles  and  naso-labial  folds  are  prominent,  but  there  is  not  marked 
anaemia  unless  some  complication  be  present.  In  milder  forms  there  is 
nothing  peculiar  in  the  expression.  General  wasting  of  the  body  is  a 
prominent  symptom  in  severe  forms;  but  in  elderly  patients,  suffering 
from  mild  forms  of  diabetes,  obesity  is  not  infrequent.  In  severe  forms 
the  patient  often  complains  most  of  general  weakness. 

Urine. — The  quantity  is  increased — in  severe  cases  greatly  (150-250  oz. 
daily),  in  mild  cases  slightly.  The  colour  is  pale,  usually  straw-coloured ; 
often,  but  not  always,  the  tint  is  slightly  greenish  yellow.  In  the  very 
mild  forms  the  colour  is  normal.  The  urine  is  usually  clear,  and  a  mucous 
cloud,  when  present,  often  floats  to  the  top  of  the  urine  glass.  In  diabetic 
females  the  urine  is  often  turbid,  owing  to  the  presence  of  pus  and  epithelial 
cells  from  the  vulva.  The  reaction  is  nearly  always  acid.  The  specific 
gravity  is  above  the  normal,  and  may  reach  1030,  1045,  or  more.  In  very 
mild  cases,  and  in  temporary  glycosuria,  the  specific  gravity  may  be  normal 
or  even  subnormal.  The  most  important  change  in  the  urine  is  the  presence 
of  grape  sugar.  The  amount  of  sugar  present  varies  according  to  the 
severity  of  the  case,  from  0*5  up  to  8  or  10  per  cent. ;  and  the  daily  excre- 
tion may  reach  2000  or  3000  grs.  or  more.  The  patient  frequently  notices 
that  flies  are  attracted  to  his  urine,  and  that  if  a  drop  of  it  should  fall  on 
any  object  and  be  allowed  to  dry  a  white  deposit  is  left  behind. 

The  sugar  excretion  is  increased  by  food — diminished  by  fasting.  In 
many  mild  cases  the  excretion  during  the  night  is  very  small,  or  the  night 
urine,  passed  before  breakfast,  may  be  free  from  sugar ;  whilst  the  day 
urine  contains  a  large  quantity  of  sugar.  The  sugar  excretion  is  increased 
by  carbohydrate  food,  but  diminished  by  a  nitrogenous  diet.  In  mild 
cases,  withdrawal,  or  sometimes  even  restriction,  of  the  carbohydrates  of 
the  diet  causes  the  glycosuria  to  disappear ;  but  in  severe  cases  the  most 
rigid  nitrogenous  diet,  and  even  fasting,  fails  to  remove  the  glycosuria. 
Of  the  carbohydrate  articles  of  diet,  grape  sugar  causes  the  greatest  sugar 
excretion,  fruit  sugar  (laevulose)  is  only  half  as  injurious,  whilst  milk  sugar 
and  cane  sugar  occupy  a  position  midway.  Starch  is  much  less  injurious 
than  sugar.  Fats  and  moderate  quantities  of  alcohol  do  not  increase  the 
sugar  excretion.  Muscular  exercise  diminishes  the  sugar  excretion  in  mild 
cases,  but  increases  it  in  the  severe  forms  with  wasting.  The  glycosuria 
and  other  diabetic  symptoms  are  diminished  or  arrested  by  intercurrent 
affections.  When  phthisis  occurs  as  a  complication,  the  sugar  excretion 
may  cease  just  before  the  fatal  termination. 

Albuminuria  is  usually  absent  at  first,  but  often  appears  at  a  late  stage 
— in  44  per  cent,  of  cases.  Usually,  however,  the  amount  of  albumin  is 
very  small,  and  is  not  associated  with  nephritis ;  in  a  few  cases  it  is  more 
abundant,  and  due  to  chronic  parenchymatous  or  interstitial  nephritis. 
Owing  to  the  excess  of  nitrogenous  food,  the  urea  excretion  is  increased ; 
in  a  few  cases  only  is  the  increase  due  to  destruction  of  the  albumin  of  the 
body.  Sometimes  there  is  an  abundant  deposit  of  oxalate  of  lime  in  the 
urine  glass  ;  in  mild  cases,  there  is  frequently  a  deposit  of  uric  acid  crystals. 
In  the  most  severe  forms  of  the  disease,  the  addition  of  a  solution  of 


DIABETES  MELLITUS.  511 

perchloride  of  iron  to  the  urine  often  produces  a  dark  brownish  red  colora- 
tion (Gerhardt's  reaction),  which  is  probably  due  to  the  presence  of  diacetic 
acid  or  some  closely  allied  body.  The  urine  often  contains  acetone,  and 
/s-oxybutyric  acid  is  frequently  present  in  the  severe  forms  at  a  late  stage. 

The  blood. — Normal  blood  contains  a  very  small  quantity  of  sugar — 
from  1  to  17  per  1000  (Pavy,  Seegen).  In  diabetes  mellitus  the  amount  is 
increased,  often  markedly — it  may  reach  27  to  57  per  1000.  A  milky 
condition  of  the  blood  has  occasionally  been  noted  on  post-mortem  ex- 
amination, and  in  some  cases  a  milky  serum  has  separated  when  the  blood 
has  been  kept  for  some  time.  This  condition  has  been  shown  to  be  due  to 
excess  of  fat. 

The  writer  has  discovered  a  simple  method  of  distinguishing  diabetic 
blood  from  non-diabetic  blood.  A  drop  of  blood  taken  from  the  finger  is 
sufficient  to  give  the  reaction.  About  40  c.mm.  of  water  are  placed  at  the 
bottom  of  a  small  narrow  test-tube.  The  patient's  finger  is  pricked  and  20 
c.mm.  of  blood  are  added  to  the  water  in  the  test-tube.  The  capillary  tube 
of  a  Gowers'  htemoglobinometer  may  be  used  for  taking  the  blood  from  the 
pricked  finger.  Then  1  c.c.  (1000  c.mm.)  of.  a  watery  solution  of  methy- 
lene-blue  (1  in  6000)  is  added,  and  finally  40  c.mm.  of  liquor  potassee  (B.P.). 
The  fluids  in  the  tube  are  well  mixed.  As  a  control  experiment  a  second 
tube  is  used,  containing  the  same  quantity  of  non-diabetic  blood,  along  with 
the  same  properties  of  water,  methylene-blue,  and  liquor  potassee.  The 
mixture  in  each  tube  has  a  deep  blue  colour.  Both  tubes  are  placed  in  a 
beaker  or  large  wide  test-tube  containing  water.  By  the  heat  of  a  spirit- 
lamp  the  water  in  the  beaker  is  boiled  for  about  four  minutes.  At  the  end 
of  this  time  the  fluid  in  the  tube  containing  the  diabetic  blood  becomes 
pale  yellow  in  colour,  whilst  that  in  the  tube  containing  the  non-diabetic 
blood  remains  blue  or  bluish  green.  It  is  important  that  the  test-tubes 
used  should  be  narrow,  and  that  they  should  be  kept  quite  still  whilst  in 
the  water  bath.  The  writer  has  invariably  obtained  the  reaction  just 
described  in  diabetes  mellitus,  but  never  in  any  other  disease  or  in 
healthy  individuals.  The  reaction  is  due  to  the  greater  reducing  power 
of  diabetic  blood. 

Other  symptoms  and  complications. — The  temperature  is  normal  or 
subnormal  except  when  complications  occur.  The  skin  is  dry  and  rough 
in  severe  cases,  but  in  mild  cases  it  is  often  normal.  Localised  pruritus, 
especially  about  the  vulva,  is  a  common  symptom.  Pruritus  of  the  vulva 
is  often  followed  by  erythema  and  eczema,  and  pruritus  of  the  glans  penis 
by  balanitis  and  oedema  of  the  prepuce.  These  complications  are  due  to 
irritation  caused  by  the  saccharine  urine.  Boils  and  carbuncles  sometimes 
develop.  Gangrene,  moist  or  dry,  may  occur  in  patients  over  45.  It  is 
usually  associated  with  arterio-sclerosis,  or  it  follows  some  injury  or  wound 
of  the  skin.  Other  very  rare  skin  affections  are  perforating  ulcers  of  the 
foot,  anasarca  (without  albuminuria  or  evidence  of  cardiac  disease),  and  dia- 
betic xanthoma.  Eecently  a  bronzing  of  the  skin  has  been  described  in 
one  form  of  the  disease  (diabete  bronztf). 

The  mouth  is  usually  dry  and  the  saliva  scanty.  The  gums  are  fre- 
quently inflamed  and  swollen,  and  the  teeth  carious  in  chronic  cases.  The 
tongue  is  often  red  and  raw  in  appearance  in  the  severe  cases.  Thirst  is 
one  of  the  most  prominent  symptoms,  and  the  appetite  is  generally  much 
increased ;  but  in  the  mild  cases  both  symptoms  may  be  absent.  Consti- 
pation is  very  common. 

Tuberculous  phthisis  is  frequent  in  severe  forms  of  the  disease.     In 


512  GENERAL  DISEASES. 

one  hundred  hospital  diabetic  patients  signs  of  phthisis  were  present  in 
twenty -nine.  In  elderly  patients  and  in  mild  forms,  phthisis  is  much  less 
frequent.  The  phthisis  of  diabetic  patients  is  nearly  always  tuberculous ; 
tubercle  bacilli  are  frequently  found  in  the  sputum ;  often  cough  and  expec- 
toration are  slight ;  haemoptysis  is  rare ;  and  the  temperature  is  often  not 
much  above  normal.  The  changes  found  post-mortem  are  generally  much 
more  extensive  than  is  suspected  from  the  symptoms.  Other  lung  affec- 
tions are  occasionally  met  with — chronic  non-tuberculous  pneumonia, 
gangrene,  broncho-  and  croupous  pneumonia.  In  severe  forms  of  diabetes, 
at  a  late  stage,  the  breath  has  often  a  peculiar  smell,  resembling  chloro- 
form, due  to  the  presence  of  acetone. 

The  heart  usually  presents  no  signs  of  disease,  at  least  in  the  severe 
forms.  It  was  normal  in  ninety-three  out  of  a  himdred  cases  examined  by 
the  writer.  Cardiac  enlargement  has  been  recorded,  however,  in  some  cases ; 
and  diabetes  occasionally  terminates  with  cardiac  failure.  As  already 
mentioned,  in  late  stages  of  the  disease,  slight  albuminuria  is  a  frequent 
complication  (44  per  cent.),  but  the  albuminuria  is  usually  not  due  to 
nephritis.  Occasionally,  however,  diabetes  is  complicated  with  chronic 
parenchymatous  or  interstitial  nephritis. 

Defects  of  vision  are  not  infrequent.  Cataract,  generally  of  the  soft 
variety,  is  the  most  important  ocular  complication  in  9  per  cent,  of  cases. 
Vitreous  opacities,  paresis  of  accommodation,  short-sightedness  developing 
late  in  life,  retinitis,  and  amblyopia  are  sometimes  met  with.  Diabetic 
retinitis  is  rare,  7  per  cent,  of  cases ;  it  occurs  only  in  patients  over  the 
age  of  40.  In  one  variety,  small  scattered  punctiform  retinal  haemorrhages 
are  seen ;  in  another  variety,  small  "  curdy  "  white  patches,  often  arranged 
in  an  incomplete  circle  around  the  yellow  spot,  are  observed  near  the 
centre  of  the  retina.  Amblyopia,  like  tobacco  amblyopia,  with  central 
scotomata  for  colours,  and  without  ophthalmoscopic  changes,  is  sometimes 
met  with. 

Loss  of  sexual  power  is  not  infrequent  in  males ;  in  females  sexual 
desire  is  said  to  be  diminished  in  severe  forms,  but  increased  in  mild  cases 
in  elderly  women.     Amenorrhcea  may  occur.     Abortion  is  common. 

The  intellect  generally  remains  clear,  but  drowsiness,  mental  dulness, 
and  melancholia  are  common.  Troublesome  cramps  at  night  in  the  calf 
muscles  are  frequent,  and  may  be  the  first  symptom  of  the  disease  to 
attract  the  patient's  attention.  Tenderness  of  the  calf  muscles  and  pains 
in  the  legs  are  common;  occasionally  there  are  well-marked  symptoms  of 
peripheral  neuritis,  with  "  dropping  "  of  the  feet,  as  in  the  alcoholic  form. 
Cases  of  monoplegia,  probably  neuritic,  are  also  on  record.  When  there  are 
pains  and  tenderness  or  other  neuritic  symptoms  in  the  legs,  the  knee-jerks 
are  usually  absent ;  but  they  are  also  often  absent  when  there  are  none  of 
these  neuritic  symptoms.  Amongst  one  hundred  hospital  patients,  mostly 
suffering  from  a  severe  form  of  the  disease,  the  writer  found  the  knee-jerks 
both  absent  in  forty-nine ;  one  present  one  absent  in  six  ;  both  present  in 
forty-five.  In  private  practice  and  amongst  milder  forms  of  the  disease,  the 
knee-jerks  are  much  less  frequently  absent.  At  a  later  stage  the  loss  of 
knee-jerks  is  more  common :  it  was  lost  in  73  per  cent,  during  the  last  few 
days  of  life,  and  in  twenty  out  of  twenty-three  y  cases  of  diabetic  coma. 
"When  the  knee-jerks  are  lost,  the  wrist-jerks  are  usually  also  absent,  but 
the  superficial  reflexes  normal  or  increased. 

Diabetic  coma. — The  most  frequent  termination  of  diabetes  is  in  coma. 
It  is  especially  common  in  severe  forms  of  the  disease  hi  young  persons. 


DIABE  TES  MELLITUS.  5 1 3 

A  long  railway  journey,  great  mental  worry  or  anxiety,  great  muscular 
exertion,  sudden  change  of  diet,  and  sometimes  severe  constipation,  appear 
to  act  as  exciting  causes,  when  the  patient  is  suffering  from  a  severe  form 
of  the  disease,  and  the  urine  gives  a  marked  reaction  with  perchloride 
of  iron.  The  first  symptoms  of  this  complication  are  rapidity  of  the 
pulse,  most  characteristic  dyspnoea,  epigastric  pain,  nausea,  and  occasional 
vomiting.  The  patient  becomes  restless,  and  then  drowsiness  gradually 
develops.  The  pulse  becomes  very  feeble,  and  dyspnoea  is  one  of  the 
most  prominent  symptoms.  The  number  of  respirations  per  minute  is 
often  only  slightly  increased,  but  the  inspirations  and  expirations  are 
very  deep,  and  the  breathing  has  a  peculiar  sighing  or  panting  character 
— the  air  hunger  of  Kussmaul.  Usually  the  bowels  are  constipated ;  the 
skin  is  cold  and  livid,  and  the  temperature  subnormal,  95°-97°  F.  In  a 
very  few  cases  there  is  finally  an  elevation  of  temperature,  102°-104°  F. 
The  breath  and  the  urine  have  usually  a  chloroform-like  smell  from 
acetone.  The  urine  generally  gives  a  distinct  reaction  for  acetone,  and 
a  brownish  red  coloration  is  usually  obtained  with  perchloride  of  iron — 
the  diacetic  acid  reaction.  The  urine  contains  also  /3-oxybutyric  acid,  and 
the  ammonia  excretion  is  increased.  The  sugar  excretion  and  the  quantity 
of  urine  often  diminish  with  the  onset  of  comatose  symptoms.  The  urine 
usually,  if  not  invariably,  contains  a  small  quantity  of  albumin  and  a  large 
number  of  granular  casts  in  the  common  variety  of  diabetic  coma.  The 
knee-jerks  are  usually  absent  twenty  out  of  twenty-three  cases.  The 
drowsiness  steadily  increases  until  the  patient  is  comatose;  sometimes, 
however,  the  coma  is  not  complete,  and  the  patient  can  be  roused  to  take 
his  medicine  up  to  the  last.  Death  usually  occurs  within  forty-eight  hours 
after  the  development  of  coma. 

The  symptoms  just  enumerated  are  those  of  the  common  form  of  dia- 
betic coma,  Kussmaul's  variety  ;  but  there  are  two  other  rare  forms — 
(1)  The  alcoholic  forms,  in  which  there  is  marked  excitement  at  the  onset, 
like  that  of  alcoholic  intoxication,  and  in  which  dyspnoea  is  not  a  pro- 
minent symptom.  (2)  Diabetic  collapse,  described  by  Dreschfeld  and 
Frerichs ;  in  this  form  there  are  signs  of  cardiac  failure,  followed  by  coma ; 
the  breath  has  not  the  acetone  smell,  and  the  urine  does  not  give  the 
perchloride  of  iron  reaction. 

Pathological  anatomy  reveals  no  characteristic  lesions  in  diabetic  coma ; 
the  most  constant  changes  are  those  in  the  renal  epithelium.  In  the 
variety  described  above  as  diabetic  collapse,  the  cause  is  probably  cardiac 
failure,  from  degeneration  of  the  cardiac  muscle. 

In  the  common  form  of  coma  many  views  as  to  the  causation  have  been 
held.  Fat  embolism,  ptomaine  poisoning  from  the  intestine,  poisoning  by 
acetone,  or  diacetic  acid,  have,  at  various  times  and  by  different  authors, 
been  regarded  as  the  cause.  But  there  is  considerable  evidence  against  all 
of  these  views.  At  present  there  is  much  evidence  in  favour  of  an  intoxica- 
tion of  the  organism  by  some  organic  acid  (Stadelmann),  especially  /3-oxy- 
butyric acid.  The  urine,  as  already  mentioned,  usually  if  not  invariably, 
contains  a  small  amount  of  albumin  and  numerous  casts  in  the  common 
form  of  coma ;  the  quantity  of  urine  and  sugar  excreted  usually  diminish ; 
and  the  kidney  epithelium  often  shows  degenerative  changes  post-mortem. 
It  appears  probable,  therefore,  that  in  diabetic  coma  the  kidneys  fail  to 
eliminate  some  toxic  substances,  and  that  poisoning  is  the  result. 

Forms  of  diabetic  mellitus. — (1)  In  the  mild  forms  removal  of  carbo- 
hydrates from  the  diet  causes  the  sugar  excretion  to  cease.  The  patients 
vol.  1. — 33 


514  GENERAL  DISEASES. 

are  often  past  middle  age,  and  not  infrequently  stout  or  gouty.  (2)  In  the 
severe  forms  withdrawal  of  carbohydrates  from  the  diet  fails  to  arrest  the 
sugar  excretion ;  usually  there  is  marked  wasting.  An  acute  form  is  some- 
times met  with  in  children  and  young  persons,  in  which  death  occurs  in  a 
few  weeks  or  months  after  the  onset  of  the  disease.  (3)  There  are  also  inter- 
mediate or  transitional  varieties,  the  mild  form  passing  into  the  severe. 

(4)  In  the  mild  forms  occasionally  there  are  no  indications  of  the  disease, 
except   those  obtained  by  examination  of  the   urine — diabetes  decipiens. 

(5)  Occasionally  in  mild  forms  the  symptoms  disappear  from  time  to  time 
— intermittent  diabetes.  (6)  Hanot,  Chauffard,  and  others  have  described 
a  rare  form  of  diabetes,  in  which  there  is  bronzing  of  the  skin  and  hyper- 
trophic cirrhosis  of  the  liver — diaMte  bronze'. 

Termination. — In  severe  forms  a  fatal  termination  occurs  in  a  few 
years,  occasionally  in  a  few  months.  In  mild  cases,  especially  in  elderly 
persons,  the  duration  may  be  many  years,  ten  to  twenty.  When  nephritis 
occurs  as  a  complication,  the  symptoms  of  diabetes  may  gradually  disap- 
pear, and  only  those  of  nephritis  then  remain.  If  phthisis  occurs  as  a 
complication,  finally  the  sugar  excretion  and  diabetic  symptoms  may  dis- 
appear shortly  before  death.  In  a  few  cases  diabetes  mellitus  has  given 
place  to  diabetes  insipidus. 

The  most  frequent  fatal  termination  is  by  diabetic  coma — thirty-five 
in  fifty-eight  cases ;  pulmonary  phthisis  is  the  next  most  frequent  termina- 
tion— twelve  in  fifty-eight  cases.  Death  may  also  occur  from  gangrene, 
carbuncle,  and  the  various  complications  already  mentioned. 

Diagnosis  and  prognosis. — The  diagnosis  is  easy.  Mistakes  are 
sometimes  made  because  the  patient  complains  only  of  wasting  or  of  one  of 
the  complications,  and  the  urine  examination  is  omitted.  It  is  important 
not  to  mistake  temporary  glycosuria  for  diabetes.  If  the  patient  be  first 
seen  in  the  comatose  state,  and  the  urine  cannot  be  obtained,  the  reaction 
of  the  blood  with  methylene-blue,  already  described,  is  diagnostic. 

Much  depends  on  the  patient's  age  and  on  the  form  of  the  disease.  In 
severe  forms,  and  in  persons  under  middle  age,  the  prognosis  is  bad. 
Marked  wasting,  the  presence  of  the  perchloride  of  iron  reaction  in  the 
urine,  and  pulmonary  tuberculosis,  are  very  unfavourable  signs.  In  mild 
forms  of  the  disease  in  elderly  people,  especially  in  the  obese  or  gouty,  the 
prognosis  is  much  more  favourable ;  as  already  indicated,  in  such  cases  life 
may  be  prolonged  for  many  years. 

Treatment. — Before  commencing  the  treatment  of  a  case  of  diabetes, 
it  is  important  to  determine  the  form  of  the  disease,  as  the  treatment  differs 
in  the  mild  and  severe  varieties.  The  results  obtained  in  the  former 
variety  are  often  good,  whilst  those  in  the  latter  are  very  unsatis- 
factory, especially  in  young  persons.  The  daily  amount  of  urine  and  sugar 
excreted  should  be  determined,  the  urine  should  be  tested  with  perchloride 
of  iron,  and  the  patient's  weight  noted.  Then  the  carbohydrate  articles  of 
food  should  be  withdrawn  from  the  diet,  and  the  patient  should  be  fed  on  a 
test  diet  of  nitrogenous  and  fatty  food  only.  If  the  sugar  excretion  should 
be  arrested  by  this  diet,  the  case  belongs  to  the  mild  form  of  the  disease : 
a  little  carbohydrate  in  the  form  of  bread  should  then  be  allowed,  and  the 
amount  gradually  increased  until  the  glycosuria  returns.  The  amount  of 
bread  which  must  be  allowed  before  the  glycosuria  returns  is  an  indication 
of  the  quantity  of  carbohydrates  the  patient  can  tolerate,  and  of  the  mild- 
ness or  severity  of  the  disease. 

In  the  severe  form  of  diabetes  the  withdrawal  of  carbohydrates  from 


DIABETES  MELLITUS. 


5J5 


the  food  does  not  cause  the  sugar  excretion  to  cease.  If  the  patient  be 
wasted,  and  if  the  urine  give  a  brownish  red  coloration  with  perchloride 
of  iron,  a  rigid  diet  should  only  be  continued  for  a  very  short  time ;  and 
in  such  severe  cases  many  authors  think  that  this  test  diet  should  not  be 
commenced  suddenly,  since  by  such  a  procedure  there  is  a  danger  of  excit- 
ing diabetic  coma  (Ebstein,  Naunyn,  and  others).  In  these  severe  cases,  if  it 
be  thought  desirable  to  try  the  effect  of  a  rigid  diet,  it  is  best  commenced 
cautiously,  potatoes  being  excluded  first,  then  bread,  and  afterwards  other 
carbohydrates ;  and  it  is  well  to  allow  a  few  days  to  elapse  before  all  carbo- 
hydrates are  excluded. 

Having  determined  the  form  of  the  disease  and  the  action  of  a  rigid  diet, 
the  future  dietetic  treatment  may  be  prescribed.  A  record  should  be  kept 
of  the  sugar  excretion,  and  of  the  weight  of  the  patient.  The  latter  is  very 
important,  and  is  a  useful  guide  with  respect  to  the  diet.  With  the  excep- 
tion of  cases  associated  with  obesity,  it  is  important  to  endeavour  to 
regulate  the  quantity  and  quality  of  the  food,  so  that  the  patient  does  not 
lose  weight. 

In  accurate  observations  on  the  effect  of  diet,  the  amount  of  heat  which  could 
be  produced  by  the  oxidation  of  the  various  articles  of  food  is  often  calculated  and 
expressed  in  calories  (a  calorie  being  the  amount  of  heat  required  to  raise  1  kilo, 
of  water  1°  C).  1  grm.  of  proteid  and  1  grm.  of  carbohydrate  each  yield  by  oxida- 
tion about  4  calories,  and  1  grm.  of  fat  yields  9  calories.  The  quantity  of  these 
three  substances  in  the  diabetic  diet  is  calculated,  and  their  value  expressed  in 
calories.  From  the  total,  the  value,  in  calories,  of  the  sugar  lost  in  the  urine  is 
subtracted,  and  the  remainder  ought  to  be  not  less  than  2300  calories  daily. 
This  is  the  value  in  calories  of  the  food  required  daily  by  a  healthy  man. 

In  the  mild  forms  of  the  disease  the  test  diet  shows  that  there  are  two 
sub-varieties.  In  one  class  of  cases  the  withdrawal  of  all  the  carbohydrates  of 
the  diet  is  necessary  to  cause  the  sugar  excretion  to  cease,  and  the  addition 
of  the  smallest  amount  of  bread  causes  the  sugar  to  return  in  the  urine ; 
in  other  cases  the  patient  can  tolerate  a  certain  amount  of  carbohydrate 
food,  and  it  is  only  necessary  to  restrict  the  carbohydrates  to  check  the 
sugar  excretion.  In  either  case  the  diet  which  is  just  sufficient  to  arrest 
the  sugar  excretion  should  be  prescribed.  After  a  period  of  restriction,  it 
is  sometimes  found  that  the  patient  can  tolerate  more  and  more  carbo- 
hydrate food  without  the  sugar  excretion  returning,  and  the  diet  may  then 
be  relaxed ;  but  in  other  cases,  unless  the  exclusion  of  all  carbohydrate  food 
be  continued,  sugar  is  excreted  in  the  urine.  In  the  latter  cases,  after  a  few 
weeks  or  months,  often  the  patient  will  no  longer  tolerate  a  strictly  rigid 
diet,  or  it  is  found  that  he  is  losing  weight.  It  is  then  frequently  necessary 
to  relax  the  diet,  especially  as  regards  the  amount  of  bread,  and  to  be 
content  if  by  moderate  restriction  of  the  carbohydrates  we  can  keep  the 
daily  sugar  excretion  down  to  about  500  grs. 

In  the  severe  forms  of  the  disease,  especially  when  the  urine  gives  a 
marked  brownish  red  coloration  with  perchloride  of  iron,  and  when  there  is 
great  wasting,  it  is  now  the  opinion  of  most  physicians  that  a  very  rigid 
diet  has  a  bad  effect.  In  these  cases,  if  a  strict  diet  be  prescribed  in  order 
to  test  the  exact  form  of  the  disease,  it  should  only  be  continued  for  a  very 
short  time  (as  already  mentioned).  In  the  severe  forms  the  diet  should 
consist  of  nitrogenous  and  fatty  food,  with  a  small  quantity  of  carbohydrates, 
chiefly  in  the  form  of  bread,  but  all  saccharine  food  should  be  avoided.  Fatty 
food  is  especially  valuable.     Cream  and  butter  should  be  given  in  large 


516  GENERAL  DISEASES. 

quantities,  and  a  moderate  amount  of  milk  should  be  allowed.  If  coma 
appears  to  be  threatening,  or  if  the  brownish  red  reaction  with  perchloride 
of  iron  in  the  urine  should  become  marked,  the  starchy  carbohydrates  in 
the  food  should  be  increased  a  little. 

Articles  of  food,  in  diabetes. — When  it  is  desired  to  place  a  diabetic 
patient  on  a  rigid  diet  in  order  to  determine  the  form  of  the  disease,  or 
when  a  rigid  diet  is  desirable  in  the  treatment,  the  following  articles 
should  be  sanctioned  or  forbidden : — 

Sanctioned. — Butchers'  meat  of  all  kinds  (except  liver) ;  potted  and 
preserved  meats.  Ham,  tongue,  bacon.  Poultry,  game.  Fish  (fresh,  dried, 
and  preserved) ;  sardines,  shrimps.  Broths,  animal  soups,  and  jellies  (pre- 
pared without  the  addition  of  sugar  or  starchy  materials).  Eggs,  cheese, 
cream.  Butter,  suet,  oils,  and  fats.  Custard  (without  sugar).  Reliable 
bread  substitutes  (gluten  bread,  almond  and  aleuronat  cakes).  Green 
vegetables — mustard  and  cress,  watercress,  endive,  lettuce,  spinach, 
turnip-tops,  cabbage,  broccoli,  brussels  sprouts,  spring  onions,  cucumber. 
Mushrooms.  Pickles  (cucumber,  walnuts,  and  onions).  Nuts  (walnuts, 
almonds,  filberts,  hazel  nuts,  Brazil  nuts),  but  not  chestnuts. 

Forbidden, — Sugar ;  saccharine  and  farinaceous  articles  of  food.  Pastry 
and  farinaceous  puddings.  Rice,  sago,  arrowroot,  tapioca,  macaroni,  ver- 
micelli, semolina.  Potatoes.  Wheaten  bread  and  biscuits.  Carrots, 
turnips,  parsnips,  beetroot,  beans,  peas,  large  onions.  Liver.  Oysters, 
cockles,  mussels,  the  "  puddings  "  of  crabs  and  lobsters.  Honey.  All  sweet 
fruit  and  dried  fruits. 

Beverages. — Sanctioned, — Water,  soda-water,  and  mineral  waters.  Tea, 
coffee.  Dry  sherry,  claret,  Burgundy,  hock,  Moselle,  Ahr  wines,  most  Rhine 
wines,  Austrian  and  Hungarian  table  wines  (all  in  moderate  quantities, 
however).     Brandy  in  small  quantities. 

Forbidden. — Port,  Tokay,  champagne,  and  sweet  wines.  Fruit  juices 
and  syrups.  Sweet  lemonade.  Liqueurs,  beer,  ale,  porter,  and  stout. 
Rum  and  sweetened  gin.     Cocoa  and  chocolate.     Milk  in  large  quantities. 

This  diet  table  of  course  requires  modification  according  to  the 
form  of  the  disease,  and  in  severe  cases  should  be  less  rigid,  as  already 
indicated. 

Dietetic  treatment. — Nearly  all  kinds  of  animal  food  may  be  allowed, 
with  the  exception  of  liver,  oysters,  cockles,  mussels,  crabs,  and  lobsters, 
which  contain  much  carbohydrate  material. 

Milk  contains  4  per  cent,  of  objectionable  milk  sugar ;  but  it  contains 
also  a  large  amount  of  valuable  fat  and  albumin.  The  glycosuria  is  in 
some  cases  unchanged,  in  others  increased  by  milk.  Cream,  which  contains 
less  milk  sugar,  but  seven  times  the  amount  of  fat,  may  be  allowed  to  all 
diabetic  patients,  as  the  total  amount  of  sugar  in  the  quantities  which  can 
be  usually  taken  is  very  small.  Milk  may  be  allowed  in  the  very  severe 
cases  ;  and  also  in  small  quantities  in  those  mild  cases  in  which  it  causes 
no  increase  of  the  glycosuria.  The  writer  has  prepared  an  artificial  milk 
which  may  be  taken  freely  by  all  diabetic  patients :  four  tablespoonfuls  of 
cream  are  added  to  a  pint  of  water  and  mixed  well.  At  the  end  of  twelve 
hours  the  fat  of  the  cream  will  have  floated  to  the  surface ;  it  will  be  found 
almost  free  from  sugar,  which  will  remain  dissolved  in  the  pint  of  water. 
The  cream  fat  on  the  surface  of  the  water  is  skimmed  off  carefully,  placed 
in  another  vessel,  and  to  it  are  added  water,  the  white  of  an  egg,  and  a  little 
salt,  and  a  trace  of  saccharin  if  desired.  By  practice  a  palatable  artificial 
milk  can  be  thus  prepared  practically  free  from  sugar.     The  egg  albumin 


DIABETES  MELLITUS.  517 

may  be  omitted,  according  to  the  patient's  preference.  Fats  of  all  kinds  are 
of  great  value,  especially  in  the  form  of  butter,  cream,  bacon,  cheese,  eggs, 
suet,  and  cod-liver  oil.  A  little  brandy  and  water  aids  the  digestion  of  these 
articles. 

As  regards  the  various  carbohydrates,  starch  is  less  injurious  than 
sugar.  Fruit  sugar  (levulose)  is  less  injurious  than  cane  sugar  and  grape 
sugar.  In  mild  forms  a  small  amount  of  fruit  sugar  is  utilised  in  the  system. 
Fruits  which  contain  much  sugar,  such  as  grapes  and  dried  fruit,  dates,  figs, 
raisins,  currants,  etc.,  should  be  forbidden ;  but  some  fruits  contain  only 
a  very  little  sugar,  which  is  chiefly  in  the  form  of  lsevulose,  and  a  very  small 
quantity  of  such  fruit  is  sometimes  allowed  when  a  very  rigid  diet  is  not 
necessary.  Saccharin  or  saxin  should  be  used  in  place  of  sugar  to  sweeten 
tea,  coffee,  and  articles  of  food. 

Bread  contains  49  per  cent,  of  carbohydrates,  and  2  per  cent,  of  sugar, 
and  on  this  account  is  objectionable  when  a  very  rigid  diet  is  indicated ; 
but  its  substitutes  are  often  unreliable  owing  to  their  disagreeable  taste,  or 
on  account  of  the  large  percentage  of  carbohydrates  they  contain.  When 
a  very  rigid  diet  is  not  indicated,  it  is  best  to  allow  a  small  quantity  of 
ordinary  white  bread;  but  if  for  diagnosis  or  treatment  a  strict  diet  is 
desired,  a  reliable  bread  substitute  may  be  given  for  a  time.  The  follow- 
ing are  the  most  useful  bread  substitutes: — (1)  Gluten  bread,  which  ought 
to  contain  only  a  very  small  amount  of  starch;  but  many  preparations 
contain  much  starch,  and  therefore  a  rough  test  with  iodine  is  necessary 
before  recommending  any  specimen.  (2)  Soya  biscuit  and  bread,  prepared 
from  the  soya-bean.  The  taste  is  often  objectionable,  however,  and  the 
preparations  not  infrequently  contain  a  large  amount  of  starch.  (3) 
Almond  cakes.  Four  oz.  of  almond  flour  are  mixed  with  a  little  water  and 
German  yeast.  The  mixture  is  allowed  to  stand  in  a  warm  place  for 
twenty  minutes,  then  an  egg  beaten  up,  and  a  little  cream  and  water  are 
added  and  a  paste  formed,  which  is  divided  into  cakes  and  baked  for  fifteen  to 
thirty  minutes.  (4)  Cocoa-nut  cakes.  They  are  prepared  in  the  same  way  as 
the  almond  cakes,  desiccated  cocoa-nut  powder  being  used  in  place  of  almond 
flour.  Both  almond  and  cocoa-nut  cakes  contain  much  fat,  and  a  little 
alcohol  aids  their  digestion.  (5)  Aleuronat.  This  is  a  vegetable  albumin 
recommended  by  Ebstein,  which  contains  only  a  very  small  amount  of 
carbohydrates.  The  writer  has  found  that  palatable  and  reliable  cakes 
can  be  prepared  as  follows : — Two  oz.  of  desiccated  cocoa-nut  powder  are 
mixed  into  a  paste  with  water  and  German  yeast.  The  mixture  is  kept  in 
a  warm  place  for  twenty  minutes,  then  two  oz.  of  aleuronat,  one  egg 
(beaten  up),  water,  and  a  little  solution  of  saccharin  are  added.  The 
whole  is  well  mixed,  divided  into  cakes,  and  baked. 

Beverages  free  or  almost  free  from  carbohydrates  may  be  allowed. 
A  little  alcohol  is  of  service  in  aiding  the  digestion  of  large  quantities  of 
fatty  food,  but  only  those  forms  should  be  allowed  which  contain  little  or 
no  carbohydrates.  Diluted  acid  drinks  are  of  service  in  relieving  the 
thirst.  A  lemonade  may  be  made  of  a  little  citric  acid  and  glycerin  in  a 
pint  of  water. 

The  patient  should  be  relieved  of  mental  anxiety  and  worry  as  much  as 
possible.  In  mild  forms  in  stout  individuals,  vigorous  exercise  in  the  open 
air  is  of  service,  but  in  the  severe  form  it  is  injurious. 

Certain  continental  spas — Carlsbad,  Marienbacl,  Keuenahr,  Vichy — are 
much  frequented  by  diabetic  patients.  In  the  mild  forms  of  the  disease, 
especially  in  stout  or  gouty  persons,  often  benefit  is  derived  from  a  visit  to 


518  GENERAL  DISEASES. 

these  spas ;  but  in  the  severe  forms  tne  long  journey  is  most  injurious,  and 
the  waters  are  useless. 

Medicinal  treatment.— We  have  no  drug  remedy  for  the  disease  in  its 
severe  form ;  but  several  drugs  have  been  shown  to  have  some  good  effect, 
especially  in  the  milder  forms.  Opium,  morphine,  and  codeine  are  of  service 
in  many  cases.  The  doses  may  be  steadily  increased  (from  \  gr.  of  opium 
up  to  2  or  3  grs.)  three  times  a  day ;  and  from  \  gr.  of  codeia  up  to  2  or  3 
grs.).  These  preparations  are  best  given  after  a  meal;  but  they  are 
liable  to  give  rise  to  severe  constipation. 

Alkaline  salts — bicarbonate  of  soda,  citrate  and  acetate  of  potash,  etc. 
— have  been  long  used.  Naunyn  strongly  advocates  very  large  quantities 
of  sodium  bicarbonate  (150  to  250  grs.  daily)  in  the  severe  forms  of  the 
disease,  when  there  is  a  marked  reaction  in  the  urine  with  perchloride  of 
iron,  or  when  coma  appears  to  be  threatening. 

The  following  drugs  amongst  many  others  have  Deen  also  recom- 
mended : — Arsenic  (in  mild  cases),  jambul  in  large  doses,  sodium  salicylate, 
bismuth  salicylate,  uranium  nitrate,  lithium  salts  (especially  in  cases  associ- 
ated with  gout).  Probably  in  mild  cases,  these  drugs,  when  pushed,  do 
have  a  beneficial  effect.  In  mild  forms  the  writer  has  obtained  very 
marked  reduction  of  the  sugar  excretion,  along  with  general  improvement, 
by  the  use  of  sodium  salicylate  (15  or  20  grs.  four  or  five  times  a  day). 
Cod-liver  oil  is  of  service  when  the  patient  is  much  wasted. 

Treatment  of  complications. — For  the  prevention  or  alleviation  of 
irritation  or  eczema  of  the  vulva  or  prepuce,  it  is  important  to  dry  the 
urethral  orifice  with  lint  or  absorbent  wool  after  micturition.  When  the 
affections  mentioned  have  developed,  the  application  of  boracic  acid  oint- 
ment or  lotion  is  of  service.  The  treatment  of  other  complications  will  be 
found  in  the  various  articles  devoted  to  these  subjects. 

Prevention  and  treatment  of  diabetic  coma. — In  the  severe  form  of 
the  disease  there  is  always  a  danger  of  coma  developing,  especially  when 
there  is  great  wasting  and  when  the  urine  gives  a  marked  reaction  with 
perchloride  of  iron.  In  such  cases,  over-exertion,  loug  railway  journeys, 
sudden  change  of  diet,  are  dangerous,  and  constipation  should  be  avoided. 
When  coma  appears  threatening,  the  diet  should  not  be  rigid.  Cream, 
milk,  and  fatty  food  should  be  given  freely,  and  a  small  amount  of  carbo- 
hydrates (chiefly  bread)  should  be  allowed.  Schmitz  believed  that  early 
coma  could  be  often  checked  by  purgation  with  castor-oil.  When  the  early 
symptoms  of  coma  appear,  large  doses  of  alkalies  should  be  given  at  once 
(100-400  grs.  of  bicarbonate  of  soda  in  the  twenty -four  hours).  It  may 
be  given  in  milk  in  frequent  doses,  or  as  an  effervescing  mixture  with 
citric  acid;  or  sodium  citrate  may  be  given  in  solution  in  large  doses  (Lepine). 

During  the  last  ten  years  intravenous  injections  of  alkaline  solution,  as 
suggested  by  Stadelmann,  have  been  often  employed.  The  solutions  most 
frequently  used  have  been  a  3-5  per  cent,  solution  of  sodium  bicarbonate 
in  water,  or  in  0'6  per  cent,  sodium  chloride  solution ;  often  a  solution  of 
sodium  chloride  alone  has  been  employed.  The  solution  should  be  warm 
when  used  (100°  F.).  It  is  usually  injected  into  the  median  basilic  vein  of 
the  arm.  Two  or  three  pints  should  be  injected.  Frequently  its  only  effect 
is  to  improve  the  pulse  and  to  slightly  diminish  the  coma.  Occasionally 
the  patient  regains  consciousness  for  a  short  time,  so  that  he  can  converse 
with  his  friends,  but  a  relapse  soon  occurs.  Intravenous  injections  may 
be  of  service,  therefore,  if  the  patient  has  not  seen  his  friends  for  a  long 
time.      Lepine  strongly  advocates  alkaline  intravenous  injections  hefore 


I)  I  ABE  TES  INSIPID  US.  519 

actual  coma  has  devoloped,  and  directly  the  first  symptom  of  the  commence- 
ment of  this  complication  appears.  He  thinks  that  it  is  only  at  this  stage 
that  we  can  hope  for  permanent  good  results. 

E.  T.  WILLIAMSON". 


DIABETES   INSIPIDUS. 


Diabetes  insipidus  is  characterised  by  great  thirst,  and  persistent  excre- 
tion of  very  large  quantities  of  urine  free  from  sugar  and  albumin.  The 
disease  is  sometimes  secondary  to  localised  organic  disease  of  the  brain ; 
but  in  most  cases  there  is  no  evidence  of  any  other  associated  affection. 

Etiology. — The  disease  is  very  rare.  At  the  Manchester  Eoyal 
Infirmary,  during  a  period  of  ten  years  (1888-1898),  amongst  14,575 
medical  in-patients,  there  were  only  seven  cases  of  diabetes  insipidus. 
Males  are  affected  about  twice  as  frequently  as  females.  The  disease  may 
occur  at  almost  any  age,  bat  Ealfe  has  shown  that  it  is  most  frequently 
met  with  in  early  childhood  (1-10  years),  and  in  early  middle  age  (30- 
40).  A  number  of  instances  are  on  record  in  which  there  has  been  a 
family  history  of  the  disease — brothers,  sisters,  or  parents  having  been 
affected.  Occasionally  there  is  a  family  history  of  diabetes  mellitus  or 
gout,  and  frequently  of  tuberculosis. 

The  disease  has  been  attributed  in  some  cases  to  injuries  to  the  head, 
to  worry  and  anxiety,  fright,  great  mental  excitement,  malnutrition  and 
neglect,  alcoholism,  influenza,  and  other  acute  affections,  syphilis,  and  ex- 
posure to  cold.  A  good  number  of  cases  have  been  shown,  by  post-mortem 
examination,  to  be  due  to  cerebral  disease.  Often  no  exciting  or  pre- 
disposing cause  can  be  traced. 

Pathology. — There  are  no  characteristic  morbid  anatomical  lesions 
in  diabetes  insipidus.  Often  changes  of  various  kinds  have  been  found  in 
the  portions  of  the  brain  situated  in  the  posterior  fossa  of  the  skull 
(medulla,  pons,  cerebral  peduncles,  cerebellum).  In  these  cases  diabetes 
insipidus  has  formed  a  part  of  the  symptomatology  of  the  brain  affections. 
In  the  primary  or  idiopathic  cases  an  autopsy  is  seldom  obtained,  and 
the  reports  published  have  often  been  incomplete,  or  the  changes  observed 
have  been  unimportant.  Hypertrophy  of  the  kidneys  and  dilatation  of 
the  renal  vessels  have  been  often  observed,  but  these  changes  are  probably 
secondary. 

Pathogenesis. — Temporary  polyuria  (without  glycosuria)  was  pro- 
duced by  Claude  Bernard,  by  puncture  of  the  floor  of  the  fourth  ventricle 
a  little  above  the  so-called  "  diabetic  centre."  Eckhard  has  shown  that 
section  of  the  great  splanchnic  nerve  produces  increased  urinary  excretion 
from  the  kidney  on  the  side  of  the  experiment.  Kahler  produced  per- 
manent polyuria  by  lesion  of  the  side  of  the  posterior  part  of  the  pons  and 
anterior  part  of  the  medulla. 

Diabetes  insipidus  in  man  is  regarded  by  many  as  due  to  a  disturbance 
of  the  function  of  the  kidneys — a  renal  neurosis  owing  to  vasomotor  dis- 
turbance of  the  renal  blood  vessels.  In  some  cases,  this  disturbance  is 
secondary  to  a  lesion  of  cerebral  structures  in  the  posterior  fossa  of  the 
skull,  as  already  mentioned  :  possibly  in  a  few  cases  lesion  of  the  splanchnic 
nerves  may  be  the  starting-point  of  the  affection.  In  rare  cases,  apparently 
the  symptoms  are  due  to  hysteria,  the  diuresis  being  the  result  of  drinking 
large  quantities  of  fluid. 


520  GENERAL  DISEASES. 

Symptoms. — The  two  prominent  symptoms  of  the  disease  are  thirst 
and  diuresis,  and  the  onset  may  be  insidious  or  sudden.  The  amount  of 
urine  is  very  great — greater  than  in  any  other  disease :  it  varies  from  180 
to  400  or  500  oz.  daily.  The  total  solids  are  usually  normal  in  amount, 
but  the  percentage  is  much  diminished.  The  urine  is  clear,  very  pale  with 
a  faint  yellow  tint — like  water  to  which  a  few  drops  of  urine  have  been 
added.  The  reaction  is  slightly  acid.  The  specific  gravity  is  very  low, 
under  1010;  usually  it  is  from  1002  to  1004;  sometimes  1000-5  or  1001. 
The  quantity  of  urine  is  greater  than  the  amount  of  fluids  drunk,  but  only 
a  little  greater  than  the  total  amount  of  water  in  the  liqrrids  and  solid  food 
taken.  Often  the  night  urine  is  more  abundant  than  the  day  urine; 
sometimes  the  excretion  in  the  two  periods  is  equal. 

Albumin  is  absent :  in  the  few  cases  in  which  it  has  been  found,  pro- 
bably some  complication  has  been  present.  Glucose  also  is  absent.  Not 
infrequently  inosite  has  been  detected,  but  it  is  not  important :  in  many 
cases  it  is  absent,  and  in  healthy  persons  it  is  sometimes  found  in  the  urine 
after  a  large  quantity  of  water  has  been  taken.  The  total  excretion  of 
urea  is  usually  normal;  but  in  some  cases  it  is  increased,  in  others 
diminished.  The  excretion  of  uric  acid  and  kreatine  is  usually  normal. 
Sodium  chloride  is  sometimes  increased,  sometimes  diminished :  the 
sulphates  and  phosphates  are  usually  normal.  Teissner  has  recorded  cases 
in  which  the  excretion  of  urine  and  the  amount  of  phosphates  have  both 
been  increased,  and  to  these  he  has  given  the  name  of  phosphatic  diabetes. 
Some  cases  occur  spontaneously  ;  others  are  associated  with  phthisis. 

Thirst  is  the  second  prominent  symptom ;  it  is  excessive,  and  the 
mouth  and  tongue  are  dry.  The  skin  is  usually  dry  and  the  sweat 
diminished.  The  appetite  is  often  unaltered ;  in  some  cases  it  is  increased; 
in  others  diminished.  Constipation  is  a  common  symptom.  The  general 
condition  in  some  cases  is  not  altered,  and  the  health  is  good  apart  from 
the  thirst  and  diuresis ;  in  other  cases  there  is  progressive  wasting.  There 
is  no  cardiac  hypertrophy.  Cataract  has  been  observed  in  a  few  cases. 
Hemianopsia  has  been  occasionally  recorded.  The  temperature  is  usually 
subnormal.  In  most  cases  restriction  of  the  quantity  of  fluids  taken  can 
only  be  tolerated  for  a  few  hours  or  days ;  but  a  few  cases  are  on  record 
in  which  the  symptoms  ceased,  or  very  markedly  diminished,  when  the 
fluids  were  greatly  restricted  for  a  time.  The  amount  of  urine  is  dimin- 
ished by  intercurrent  febrile  affections. 

Forms  of  the  disease.1 — (1)  Many  cases  are  on  record  in  which 
diabetes  insipidus  has  been  associated  with  chronic  brain  diseases,  chiefly 
tumour,  tubercle,  gumma,  cysticercus,  etc.,  in  the  floor  of  the  fourth  verticle ; 
sometimes  there  has  been  a  lesion  in  the  medulla,  pons,  or  cerebral  peduncle, 
and  occasionally  in  the  cerebellum ;  occasionally  the  cerebrum  has  been 
affected  (softening  of  the  basal  ganglia  and  cortex).  The  symptoms  of 
diabetes  insipidus  may  develop  along  with  the  cerebral  symptoms,  or  they 
may  precede  or  follow  the  onset  of  the  latter.  The  amount  of  urine  in 
such  cases  is  usually  about  140  to  200  oz.,  and  the  polyuria  continues 
until  the  death  of  the  patient,  or  ceases  only  a  few  days  before  death. 
(2)  Diabetes  insipidus  following  head  injuries  is  a  more  common  form. 
The  polyuria  is  moderate  in  amount :  it  may  disappear  in  a  fewT  weeks  or 
years,  or  it  may  continue  for  many  years  up  to  the  end  of  life.  (3)  In 
another  form  the  disease  is  associated  with  hysteria  or  epilepsy.  The 
amount  of  urine  is  usually  about  100  to  180  oz.    (4)  In  some  cases  there  is  no 

1  This  classification  is  slightly  modified  after  D.  Gerhardt. 


DIABE  TES  INSIPID  US.  521 

evidence  of  hysteria,  but  the  sudden  onset  after  fright,  and  the  sudden  dis- 
appearance of  the  symptoms,  appear  to  point  to  a  functional  cerebral 
affection.  (5)  In  the  idiopathic  cases  no  primary  disease  *?an  be 
detected ;  the  symptoms  are  marked  for  a  time,  and  there  is  wasting  and 
weakness :  then  improvement  often  occurs,  and  apart  from  the  thirst  and 
diuresis  the  patient  feels  well.  In  this  group  of  cases  the  amount  of  urine 
is  enormous.  The  duration  of  the  disease  is  very  long,  and  a  post-mortem 
examination  is  seldom  obtained.  (6)  Cases  in  which  the  disease  is  heredi- 
tary have  a  similar  course  to  the  idiopathic  cases.  (7)  Occasionally, 
cases  of  diabetes  insipidus  are  associated  with  syphilitic  disease  of  the 
brain,  or  they  occur  in  syphilitic  individuals,  and  improve  under  anti- 
syphilitic  treatment. 

Diagnosis  and  prognosis. — The  low  specific  gravity  and  the 
absence  of  sugar  distinguish  the  cases  from  diabetes  mellitus.  The  absence  of 
albumin  and  cardio- vascular  changes  separate  them  from  the  various  forms 
of  Bright's  disease.  The  persistence  of  the  diuresis  excludes  temporary 
polyuria,  which  sometimes  occurs  in  connection  with  various  diseases. 

The  prognosis  varies  according  to  the  form  of  the  disease.  In  a  few 
rare  cases  complete  or  partial  recovery  has  been  reported ;  some  cases  soon 
terminate  fatally,  especially  those  associated  with  gross  cerebral  lesions ; 
whilst  in  other  cases  the  symptoms  may  persist  for  many  years  without 
much  impairment  of  health,  and  if  death  occur  it  is  owing  to  some  acci- 
dental complication.  In  one  of  the  writer's  cases  diabetes  insipidus  has 
been  present  for  six  years.  At  first  wasting  and  other  symptoms  were  well 
marked,  but  for  several  years  there  has  been  great  improvement;  thirst  and 
diuresis  are  now  the  only  symptoms  which  trouble  the  patient ;  she  is  well 
nourished,  is  able  to  do  heavy  work,  and  feels  in  good  health. 

Treatment. — If  any  disease  be  present  to  which  diabetes  insipidus  is 
secondary,  the  treatment  should  be  directed  to  the  primary  affection. 

In  the  majority  of  cases  restriction  of  fluids  has  no  curative  effect,  and 
it  cannot  be  long  tolerated.  In  a  very  few  cases,  however,  restriction  of 
the  amount  of  fluids  is  followed  by  great  improvement  or  recovery :  such 
patients  have  usually  been  hysterical,  but  in  others  there  has  been  no 
evidence  of  hysteria,  and  the  condition  has  been  then  regarded  as  the  result 
of  the  habit  of  taking  too  much  fluid  (D.  Gerhardt). 

Galvanism  has  been  followed  by  remarkable  improvement  in  a  few  cases, 
whatever  the  exact  explanation  may  be.  One  large  electrode  (positive)  has 
been  placed  at  the  back  of  the  neck,  and  the  other  (negative)  on  the 
epigastrium  or  chin,  or  by  means  of  an  insulated  electrode,  on  the  posterior 
wall  of  the  naso-pharynx.  The  strength  of  the  current  should  be  1-5 
mille-amperes,  and  the  duration  of  the  application  about  five  minutes. 
Valerian  was  recommended  by  Trousseau  in  large  doses,  but  it  frequently 
causes  much  nausea.  Valerianate  of  zinc  and  antipyrine  have  been  occa- 
sionally followed  by  considerable  improvement.  Ergot  has  been  found  to 
diminish  the  amount  of  urine,  but  its  continued  use  is  liable  to  give  rise  to 
ergotism.  Ealfe  has  shown  that  nitro-glycerin  may  sometimes  cause 
marked  improvement.  Warm  clothing  is  important,  in  order  to  increase 
the  action  of  the  skin.  Ice  and  acid  drinks  are  of  service  in  relieving 
thirst.  As  regards  food,  restriction  of  the  carbohydrates  is  not  necessary 
in  diabetes  insipidus,  and  a  mixed  diet  may  be  taken.  It  is  advisable  to 
take  very  little  salt  with  food. 

E.  T.  "WILLIAMSON. 


522  GENERAL  DISEASES. 

SUNSTROKE. 

Syn.,  Heatstroke,  Thermic  Fever,  Siriasis. 

Syncopal,  pyrexial,  and  hyperpyrexial  conditions  occurring  in.  high 
atmospheric  temperatures,  or  as  a  consequence  of  exposure  to  the  direct 
rays  of  the  sun. 

History  and  geographical  distribution. — The  dangers  of 
exposure  to  the  direct  rays  of  a  powerful  sun  have  always  been  recognised, 
but  the  recognition  of  the  relationship  of  the  condition  known  as  "  thermic 
fever"  to  sunexposure  and  high  atmospheric  temperatures  is  comparatively 
recent,  and  is  due  principally  to  our  army  medical  officers  in  India  and  to 
American  writers. 

Although  occurring  at  times  in  temperate  climates  during  the  summer 
and  autumn  seasons  in  the  harvest  field,  and,  more  especially,  in  crowded 
cities,  these  affections  are  most  commonly  met  with  in  the  tropics,  more 
particularly  in  low-lying,  damp,  malarious  localities,  and  where  the  atmo- 
sphere is  still  and  saturated  with  watery  vapour.  Compared  to  the  coast 
lands,  the  dry  uplands  are  comparatively  exempt,  notwithstanding  the 
high  temperatures  that  are  frequently  encountered  there.  Thermic  fever 
becomes  epidemic  at  times  over  small,  occasionally  over  very  large,  areas. 
Stokers,  and  even  passengers  in  steamers  passing  through  the  tropics,  are 
not  infrequently  attacked  both  by  syncopal  sunstroke  and  by  thermic  fever ; 
the  Red  Sea,  from  June  to  November,  has  a  deservedly  evil  reputation  in 
this  respect.  The  workmen  in  sugar  factories  and  similar  industries 
associated  with  prolonged  exposure  to  high  temperatures,  are  subject,  even 
in  temperate  climates,  to  syncopal  attacks  from  over-heating  at  their  work. 

Etiology. — Confining  the  expressions  heatstroke  and  sunstroke  to 
the  sudden  collapse  which  occurs  during,  and  manifestly  in  consequence 
of  exposure  to  high  atmospheric  temperatures,  or  to  the  direct  rays  of  the 
sun,  investigation  of  individual  cases  has  demonstrated  that,  whilst  a  few 
healthy  individuals  may  suffer  in  this  way,  the  majority  of  cases  occur  in 
exhausted  or  unhealthy  individuals,  and  are  really  examples  of  simple 
syncope  or  exhaustion.  They  are  found  among  those  who  are  worn  out  by 
sustained  muscular  effort,  especially  when  the  patient  is  over-burdened 
with  thick  clothing,  among  those  labouring  under  the  effects  of  excess  in 
alcohol  or  food,  or  who  are  the  victims  of  malaria,  of  heart,  kidney,  or 
other  organic  or  constitutional  disease.  All  over-strain,  excess,  and  disease, 
therefore,  powerfully  predispose  to  syncopal  sunstroke  or  heat  exhaustion. 

The  same  remark  applies  to  thermic  fever  or  heat  apoplexy,  as  it  is  some- 
times called.  As  in  the  syncopal  type,  so  in  this  form  of  thermic  disease, 
the  direct  action  of  the  sun's  rays,  although  often  powerfully  contributory, 
is  not  necessary  to  call  forth  the  symptoms.  An  over-heated,  still,  impure, 
steamy  atmosphere,  such  as  is  often  found  in  overcrowded  barracks,  or  in 
troopships,  together  with  intemperance,  are  perhaps  the  commonest  of 
the  predisposing  etiological  elements ;  but  the  nature  of  the  premonitory 
phenomena  in  many  of  these  attacks,  the  facts  of  geographical  distribution, 
and  the  peculiarities  of  endemic  and  epidemic  occurrence,  seem  to  indicate 
that  simple  heat  or  overcrowding,  even  if  combined  with  excess,  are  not  the 
only  factors  in  every  form  of  thermic  fever. 

Many  of  these  thermic  fevers  or  heat  apoplexies  may  be  purely  the 
consequence  of  heat,  and  the  result  of  an  overthrow  of  the  thermal  dynamics 
of  the  body  by  heat  in  those  who  are  physiologically  unsound.     Many  I 


SUNSTROKE.  523 

believe  to  be  pernicious  malarial  attacks.  Possibly,  as  suggested  by 
Sambon,  others  are  the  effects  of  an  as  yet  unknown  specific  germ,  which 
finds  its  necessary  extracorporeal  conditions  only  in  the  presence  of  high 
atmospheric  temperature.  These  thermic  fevers,  like  many  other  tropical 
fevers,  have  yet  to  be  studied  in  the  light  of  a  possible  relationship  to 
the  plasmodium  of  malaria  and  to  other  germs. 

Pace  and  habituation  have  a  very  manifest  influence  on  susceptibility. 
The  European,  especially  the  new-comer  in  the  tropics,  is  much  more 
liable  to  heatstroke  and  thermic  fever  than  the  native  and  the  acclimatised 
European.  Women  and  children  suffer  less  than  men,  probably  because 
they  are  less  exposed  to  the  sun  and  are  more  temperate. 

Morbid  anatomy  and  pathology. — If  the  body  be  opened 
directly  after  death  from  thermic  fever,  the  left  heart  is  found  firmly 
contracted,  the  right  heart  dilated  and,  along  with  the  pulmonary  arteries 
and  venous  system  generally,  gorged  with  blood.  Death  manifestly  takes 
place  from  asphyxia.  Post-mortem  rigidity  sets  in  very  early,  and  decom- 
position is  rapid.  In  cases  that  have  survived  for  some  time,  evidences  of 
chronic  meningitis  may  be  discovered. 

Many  theories  have  been  propounded  as  to  the  pathology  of  thermic 
fever.  The  general  belief  is  that  the  symptoms  in  the  first  instance  are 
due  to  a  breakdown  and  consequent  inadequacy  of  the  heat-lowering 
mechanism  of  the  body,  in  the  presence  of  a  high  atmospheric  temperature. 
Subsequently,  and  when,  in  consequence  of  this,  the  body  temperature 
attains  108°,  or  over,  there  is  liability  to  coagulation  of  myosin  and 
destruction  of  the  contractility  of  all  muscular  organs,  including  the 
heart.  Wood  points  out  that  in  muscular  tissue  exhausted  by  recent  and 
sustained  effort,  the  myosin  coagulates  at  a  lower  temperature  than  when 
the  muscles  are  at  rest  and  not  exhausted ;  hence,  he  says,  those  rapid 
deaths  from  sunstroke  which  sometimes  occur  in  soldiers  during  the 
excitement  of  battle  in  a  hot  climate.  Parkes  cites  the  case  of  the  19th 
Eegiment  in  the  first  Chinese  War.  The  soldiers  fought  on  a  very  hot  day, 
and  in  heavy  and  unsuitable  clothing.  Many  cases  of  sunstroke  occurred  ; 
in  these  in  every  instance  the  men  fell  forward  on  their  faces  suddenly, 
as  if  struck  by  lightning,  and  died  immediately.  Wood  interprets  this 
as  sudden  coagulation  of  myosin  by  a  high  temperature  acting  on  an 
exhausted,  overstrained  heart  muscle. 

Symptoms. — Apyretic  type. — It  would  appear  that  there  are  two 
forms  of  the  apyretic  type  of  sunstroke — the  syncopal  and  the  algid.  In 
the  former  there  are  feelings  of  faintness  which  may  or  may  not  culminate 
in  syncope  ;  it  occasionally  proves  fatal.  In  the  latter,  in  addition  to  the 
syncopal  condition,  there  are  marked  nervous  symptoms,  accompanied, 
perhaps,  by  delirium  or  by  unconsciousness,  the  pulse  being  feeble  and 
irregular,  and  the  temperature  subnormal — 95°  or  96°;  profuse  sweating 
is  usually  a  prominent  symptom,  and  death  is  not  uncommon. 

Thermic  fever. — During  exposure  to  high  temperature,  especially 
if  prolonged  and  in  the  presence  of  the  predisposing  conditions  already 
referred  to,  thermic  fever,  or,  as  it  is  sometimes  called,  heat-apoplexy,  heat- 
asphyxia,  or  siriasis  may  supervene.  The  more  definite  symptoms  are  some- 
times preceded  for  a  few  hours  or  days  by  feelings  of  intense  languor, 
by  vertigo,  precordial  distress,  mental  confusion,  thirst,  frequency  of 
micturition;  in  other  instances  the  disease  shows  itself  quite  suddenly,  the 
patient  lapsing  almost  instantaneously  into  a  condition  of  profound 
unconsciousness.     For  a  short  time,  a  few  minutes  only  it  may  be,  the 


524  GENERAL  DISEASES. 

coma  may  be  preceded  by  delirium.  Very  often  there  is  no  warning  of 
this  description,  the  attack  coming  on  during  the  night,  perhaps,  and 
apparently  during  sleep.  When  the  attack  has  fully  developed,  the 
breathing  may  be  rapid  and  shallow,  or  it  may  be  deep  and  stertorous. 
The  face  is  sometimes  flushed,  sometimes  cyanosed,  sometimes  pale ;  the 
conjunctivae  are  injected ;  the  pupils  are  contracted,  dilated,  or  normal ; 
the  skin  is  intensely  hot,  and  either  exceedingly  dry  or  profusely  per- 
spiring. The  temperature  of  the  body  mounts  rapidly  to  anywhere 
between  108°  and  112°.  There  may  be  subsultus,  great  restlessness, 
perhaps  convulsions.  Very  soon,  if  not  relieved,  in  the  course  sometimes 
of  half  an  hour  or  at  most  a  few  hours,  the  pulse  becomes  exceedingly 
rapid,  flutters,  and  finally  fails,  and  the  patient  dies. 

Eecovery  under  favourable  conditions  from  minor  degrees  of  thermic 
fever  may  occur  ;  but  for  the  most  part  convalescence  is  slow,  the 
patient  suffering  much  from  headache,  pains  in  the  neck,  vertigo,  mental 
debility,  and  sometimes  from  insanity.  For  a  long  time  he  is  exceedingly 
sensitive  to  exposure  to  the  sun,  and  even  to  warm  and  especially  over- 
crowded rooms ;  he  gets  headache  at  once  under  such  circumstances. 
Ultimately  he  may  recover  entirely,  but  very  often  a  condition  of  per- 
manent invalidism  is  established.  What  used  to  be  known  as  ardent 
fever  may,  in  some  instances,  be  a  mild  variety  of  this  form  of  sun- 
stroke. 

Diagnosis. — The  conditions  under  which  thermic  fever  occurs  are  a 
principal  guide  in  diagnosis.  Insensibility  and  high  temperature  in  hot 
weather  are  generally  held  to  mean  thermic  fever  or  heat  apoplexy. 
That  this  diagnosis  is  always  correct  is  at  least  doubtful.  As  already 
stated,  many  of  these  are  probably  cases  of  pernicious  malarial  fevers ;  the 
microscope,  therefore,  should  always  be  used  to  settle  this  point — so 
important  in  directing  treatment.  Ordinary  apoplexy  may  be  followed 
by  high  body  temperature ;  but  the  sequence  of  events  in  this  case  is  the 
opposite  to  that  occurring  in  thermic  fever,  in  which  high  body  temperature 
precedes  the  insensibility. 

Treatment. — In  syncopal  sunstroke  the  indications  are  to  rest  the 
body,  to  get  blood  to  the  brain,  and  to  stimulate  the  heart.  The  patient 
should  be  taken  out  of  the  sun  into  a  cool  place,  laid  flat  on  his  back,  and 
fanned  gently;  his  clothes  and  accoutrements  being  unloosed,  whisky,  or 
ether,  or  ammonia  should  be  administered,  and  the  patient  otherwise 
treated  as  for  ordinary  fainting.  If  the  body  temperature  is  below 
normal,  a  warm  bath  or  rectal  injection  of  very  hot  water,  as  well  as 
diffusible  stimulants,  are  indicated. 

In  thermic  fever  the  patient  should  be  placed  in  water  at  a  temperature 
of  80°  or  85°  F.,  and  the  water  gradually  cooled  down  by  means  of  ice. 
The  duration  of  the  immersion  must  be  regulated  by  the  effect  on  the 
thermometer  kept  in  the  rectum.  Where  the  bath  is  not  possible, 
as  on  the  line  of  march,  the  patient  should  be  immediately  carried 
into  the  shade,  his  clothing  removed,  and  the  body  freely  and  frequently 
soused  with  cold  water.  Eubbing  with  ice,  when  this  can  be  got,  and 
enemata  of  iced  water  are  valuable  accessories.  Care  must  be  exercised 
not  to  push  the  cold  bath  too  far,  or  to  depress  a  failing  heart  by 
sudden  shock.  It  is  well  to  remove  the  patient  from,  the  bath  when  the 
temperature  has  sunk  to  101°  F.,  for  it  must  be  kept  in  mind  that  body 
temperature  may  continue  to  fall  to  a  dangerously  low  point,  even  after 
removal   from  the   bath.     Although  temperature   be  reduced  to  normal, 


AFRICAN  LE  THAR GY.  525 

insensibility  may  persist ;  the  prognosis  is  then  very  unfavourable.  Some- 
times a  large  blister  applied  to  the  scalp  is  of  service  in  these  circum- 
stances. In  all  cases  in  which  malaria  is  possible,  particularly  if  the 
Plasmodium  be  discovered  in  the  blood,  hypodermic  injections  of  full  doses 
of  quinine  must  be  immediately  employed  and  repeated  (see  "  Malaria "). 
Any  tendency  to  recurrence  of  high  temperature  must  be  met  immediately 
by  recourse  to  the  cold  bath  or  cold  affusion.  Eespiration  failing  whilst 
the  heart's  action  continues  suggests  the  persevering  employment  of 
artificial  respiration,  combined  with  efforts  to  reduce  temperature ;  lives 
have  been  saved  in  this  way. 

For  the  chronic  meningitis,  so  apt  to  follow  in  these  cases,  iodide  of 
potassium,  small  doses  of  mercury,  frequent  blistering  of  scalp  and  neck, 
mild  purging,  rest,  a  cold  climate,  light  diet,  and  avoidance  of  all  stimulants 
and  excitement,  are  the  best  measures. 

Prophylaxis.- — Strict  temperance  in  eating  and  drinking,  care 
about  exposure  to  the  sun,  the  use  of  pith  helmets  and  white  umbrellas, 
light  and  open  clothing,  free  ventilation,  abundant  cubic  space  in 
barracks  and  on  board  ship,  an  abundant  supply  of  drinking  water,  are 
the  best  prophylactics.  Those  who  have  once  suffered  from  sunstroke  or 
thermic  fever,  or  conditions  approaching  these,  are  unsuited  for  the 
Tropics. 

PATRICK  MANSOK 


AFRICAN   LETHARGY. 
Syn.,  Sleeping  Sickness. 


A  disease  of  the  nervous  system  endemic  in  and  limited  to  West  tropical 
Africa,  and  characterised  by  a  gradually  increasing  lethargy  and  somnolence. 
It  runs  a  slow  course  of  months  or  years,  and  is  probably  invariably 
fatal. 

History  and  geographical  distribution. — This  disease  has 
been  known  for  about  a  century ;  we  are  still  in  the  dark,  however,  as  to 
its  cause  and  pathology.  It  is  endemic,  and,  as  far  as  known,  absolutely 
confined  to  West  tropical  Africa,  being  found  here  and  there  throughout 
the  basins  of  the  Senegal,  the  Niger,  and  the  Congo.  Its  distribution  is 
singularly  capricious  :  some  districts  are  absolutely  free  from  the  disease, 
whilst  in  others  it  is  so  prevalent  at  times  as  almost  to  decimate  the 
population.  Although  sleeping  sickness  can  be  acquired  only  within  the 
endemic  area,  its  manifestation  may  not  take  place  until  many  years  after 
the  endemic  area  has  been  quitted.  Thus  a  negro  may  leave  West  Africa 
in  perfect  health,  and  remain  so  for  many  years,  and  yet  at  the  end  of  this 
time  he  may  develop  sleeping  sickness  and  die  of  the  disease  in  some 
foreign  land. 

Etiology. — Age,  sex,  and  occupation  seem  to  make  no  difference  in 
the  liability  to  this  disease.  Several  cases  may  occur  in  the  same  house, 
men,  women,  and  children  being  indiscriminately  attacked.  Hitherto  the 
negro  has  almost  exclusively  been  affected.  We  may  not  conclude  from 
this,  however,  that  there  is  any  special  racial  susceptibility,  but  only  that 
there  is  special  opportunity  in  the  case  of  the  negro. 

The  cause  of  the  disease  has  been  a  subject  of  much  speculation  ; 
amongst  other   things   manioc-eating,  intemperance   of    all   descriptions, 


526  GENERAL  DISEASES. 

exposure  to  the  sun,  malaria,  and  so  forth,  have  been  impugned.     Investi- 
gation, however,  shows  that  these  have  nothing  to  do  with  it. 

Some  time  ago  the  writer  pointed  out  that  the  negro  in  West  tropical 
Africa  frequently  harbours  a  peculiar  blood  worm,  Filaria  jjerstans.  From 
the  circumstances  that  the  geographical  distribution  of  this  parasite  *  and 
that  of  sleeping  sickness  are  singularly  limited,  and  that  their  geographical 
areas  correspond  ;  and,  furthermore,  because  the  parasite  may  live  in  the 
blood  of  its  host  for  many  years  after  the  endemic  area  has  been  quitted, 
and  that  manifestations  of  sleeping  sickness  may  not  occur  until  years 
after  the  negro  has  left  his  home,  there  seems  to  be  some  probability  of  a 
connection  between  this  parasite  and  the  disease.  The  writer  has  sug- 
gested that,  considering  the  habits  of  similar  parasites,  and  the  nature 
of  the  symptoms  produced  by  them,  it  is  possible  that  F.  persians,  by 
interfering  in  some  way  with  the  nutrition  of  the  brain,  may  bring  about 
sleeping  sickness. 

Pathology. — There  is  no  coarse  lesion  of  the  brain.  In  two  post- 
mortem examinations  of  negroes  with  this  disease,  recently  made  by  Mott, 
abundant  microscopical  evidence,  in  the  form  of  small-cell  infiltration  of 
the  perivascular  spaces  of  a  meningo-encephalitis,  was  discovered. 

Symptoms. — Sleeping  sickness  begins  very  insidiously.  A  gradually 
increasing  torpor  and  physical  languor,  together  with  occasional  attacks 
of  headache,  vertigo,  and  fever,  and  a  peculiar  apathetic,  sleepy  expression 
of  the  face,  herald  the  oncoming  of  the  disease.  By  degrees  the  lethargy 
becomes  so  pronounced  that  the  patient  ceases  to  attend  to  his  work,  and 
lies  about  asleep,  or  half -asleep,  in  the  corner  of  his  house.  After  a  time 
this  condition  becomes  more  pronounced,  so  much  so  that  he  will  no 
longer  feed  himself.  Nutrition  begins  to  suffer,  bedsores  may  form,  and 
additional  nervous  symptoms,  such  as  tremor,  convulsive  movements,  and 
temporary  paralyses  may  supervene.  The  soporose  condition  becomes  more 
intense,  and  gradually  the  patient  succumbs  from  asthenia,  or  perhaps 
may  die  in  a  convulsive  seizure.  During  the  progress  of  the  disease, 
maniacal  symptoms,  conditions  resembling  those  in  general  paralysis  of  the 
insane,  an  ataxic  drunken  gait,  and  so  forth,  may  develop,  and  come  and 
go.  The  skin  of  the  patient  is  harsh,  dry,  and  furfuraceous,  and  is  often 
affected  with  an  exceedingly  irritable  papular  or  vesicular  eruption.  The 
lymphatic  glands  of  the  neck  and  elsewhere  are  generally  swollen.  Sleeping 
sickness  may  prove  fatal  in  four  or  five  months,  or  it  may  last  for  as 
many  years.     A  year  to  eighteen  months  is  perhaps  the  average  duration. 

Diagnosis. — By  some  this  disease  has  been  confounded  with  beriberi. 
There  is  no  difficulty,  however,  in  diagnosis.  The  symptoms  of  beriberi 
are  those  of  a  peripheral  neuritis  with  special  liability  to  implication  of 
the  pneumogastric  nerves,  to  oedema,  to  dilatation  of  the  heart,  and 
palpitations.  Sleeping  sickness,  on  the  other  hand,  is  manifestly  a  disease 
of  the  central  nervous  system,  and  characterised  by  torpor,  tremor,  and,  in 
the  advanced  stages,  convulsive  seizures — phenomena  practically  unknown 
in  beriberi. 

Treatment. — ISTo  treatment,  so  far  as  known,  is  of  any  permanent 
service. 

PATKICK  MA^SOS". 

1  Quite  recently  I  have  found  this  blood-worm  in  Demerara  Indians.     There  is  no  reliable 
information  obtainable  as  to  the  presence  or  absence  of  sleeping  sickness  among  these  people. 


SECTION    II. 

DISEASES   CAUSED   BY  ANIMAL 
PAEASITES. 


PROTOZOA. 

KHIZOPODA. 

Amceba  coll — This  protozoon,  discovered  by  Losch  in  1875,  is  by  no  means 

the   only  amoeba  frequenting  the  alimentary  canal  of  man.     The  other 

amoebae,  however,  have,  so  far  as  known,  no  special  pathological  bearing. 

Amoeba  coli,  on  account  of  its  size,  the  activity  of  its  movements,  the  ease 

with  which  it  can  be  demonstrated, 

and  especially  on  account  of  its 

frequent  association  with  dysen-  ...;  .  ,,  ,    h 

tery  and  liver  abscess,  apparently 

deserves  the  considerable  amount 

of  attention  which  of  late  years  it 

has  received. 

It  resembles  in  appearance  and 
movement  the  ordinary  fresh- 
water amceba.  At  first  sight  it 
looks  like  a  minute  piece  of  clear, 
structureless  jelly,  spherical  when 
at  rest,  irregular  in  form,  with 
rounded  pseudopodia  (which  it 
keeps  constantly  pushing  out  and 
creeping  after),  when  in  a  state  of 
activity.  Under  a  magnifying 
power  of  200  to  300  diameters, 
it  is  seen  to  consist  of  a  clear, 
pellucid  outer  layer — "ectosarc" 

— of  which  the  pseudopodia  are  mainly  constituted,  and  a  somewhat 
granular  greyish  central  portion — the  "  endosarc."  The  latter  contains  an 
ill-defined  nucleus  and  nucleolus,  one  or  two  vacuoles,  and,  very  likely, 
bacteria,  blood  corpuscles,  and  debris  of  different  sorts  which  it  has 
included.     In  a  state  of  repose  the  amoeba  measures  from  15  [i  to  20  ^ 


Fig.  48. — Amceba  coli.  (a)  A.  clysenterke  fixed  and 
stained. — Councilman,  (b)  A.  dysenteries  in 
stools. — After  Lbsch. 


528  DISEASES  CAUSED  BY  ANIMAL  PARASITES. 

in  diameter ;  roughly  speaking,  its  diameter  is  equal  to  about  that  of  from 
three  to  five  blood  corpuscles. 

Amoeba  coli  occurs  in  the  healthy  faeces  both  of  man  and  of  certain 
lower  animals.  It  is  very  frequently,  though  by  no  means  always,  present 
in  the  stools  in  dysentery.  In  these,  when  present,  it  can  be  readily 
demonstrated.  All  that  is  necessary  is  to  compress  between  cover-glass 
and  slip,  so  as  to  form  a  thin  translucent  layer,  a  fragment  of  mucus  from 
the  fresh  stool ;  search  is  then  made  with  a  magnifying  power  of  100  to 
200  diameters.  In  some  cases  of  dysentery  the  parasite  is  present  in  great 
abundance,  and  many  specimens  may  be  seen  in  every  field ;  usually,  how- 
ever, several  fields  have  to  be  scrutinised  before  a  specimen  is  discovered. 
"When  the  temperature  of  the  slide  falls  below  70°  R,  the  amoeba  assumes 
its  passive  form  ;  even  in  this  condition,  with  a  little  experience,  it  may  be 
recognised  by  its  size,  spherical  form,  slightly  greenish  pellucid  tint,  and 
sharp  outline.  When  the  temperature  of  the  slide  is  raised,  in  many 
specimens,  though  not  in  all,  the  characteristic  amoeboid  movements  set  in, 
becoming  more  active  as  blood  heat  is  approached.  In  this  climate,  there- 
fore, in  making  a  microscopical  examination,  some  form  of  warm  stage  is 
desirable.  The  amoeboid  movements  may  continue  for  several  hours  ;  they 
cease  at  once  on  the  temperature  being  allowed  to  fall.  In  most  slides 
a  proportion  of  the  amoebae  maintain  their  pellucid,  spherical,  and  probably 
encysted  form,  even  if  the  temperature  be  raised. 

In  liver  abscess,  the  amoebae,  when  present,  are  readily  found  in  the  pus, 
especially  in  the  pus  escaping  from  the  drainage  tube  several  days  after 
the  abscess  has  been  opened  surgically ;  they  continue  present  so  long  as  the 
chocolate-coloured  pus,  characteristic  of  liver  abscess,  is  being  discharged, 
and  even  in  the  yellow  pus  coming  from  the  healing  abscess  cavity  or  sinus. 
I  have  frequently  found  the  amoeba  in  the  pus  coming  from  the  drainage 
tube  in  cases  in  which  several  days  before  I  had  failed  to  discover  it  in 
the  pus  coming  from  the  abscess  at  the  time  of  operation ;  that  is  to  say, 
the  special  habitat  of  the  amoeba  is  the  wall  of  the  abscess  and  the  pus  in 
immediate  contact  with  this.  It  has  been  found  in  the  pus  coughed  up 
from  liver  abscess  discharging  through  the  lungs ;  its  presence,  therefore, 
is  a  valuable  diagnostic  sign  of  this  condition. 

Amoebae  are  sometimes  demonstrable  in  the  tissues  forming  the  base  of 
certain  dysenteric  ulcers,  as  well  as  in  the  disintegrating  hepatic  tissue 
constituting  the  wall  of  a  liver  abscess. 

There  is  by  no  means  unanimity  among  pathologists  as  to  the  significance 
of  this  parasite ;  some  maintain  that  it  is  the  cause  of  a  certain  type  of 
dysentery ;  others,  that  in  such  cases  it  is  merely  a  concomitant.  Its  bearing 
on  liver  abscess  is  equally  obscure.    (See  "  Dysentery  "  and  "  Liver  Abscess.") 

Treatment. — The  amoeba  is  very  sensitive  to  quinine;  it  may  be 
made  to  disappear,  at  all  events  temporarily,  from  the  discharges,  by  injec- 
tions of  weak  solutions  of  the  drug — 1  in  2000 — whether  into  the  colon  or 
into  the  cavity  of  a  liver  abscess.  Although  Lafleur  regards  its  presence 
as,  prognostically,  very  unfavourable,  I  have  seen  many  liver  abscesses  in 
which  amoebae  abounded  recover  perfectly  after  operation.  I  therefore  do 
not  regard  it  as  an  important  factor  in  prognosis. 

GEEGABINID^E. 

Coccidium. — Several  species  of  coccidia  have  been  found  in  man.  Our 
knowledge  of  the  subject,  however,  is  extremely  fragmentary.      For  the 


GRE  GARINID/E. 


529 


present  its  principal  interest  is  an  analogical  one,  and  lies  in  the  light  it 
tends  to  throw  on  the  life  history  of  the  malaria  parasite,  and  possibly  on 
the  etiology  of  malignant  and  certain  other  growths. 

The  Coccidium  oviforme,  which  is  more  especially  a  parasite  of  the 
rabbit,  but  which  has  also  been  found  in  man,  may  be  regarded  as  a  type 
species.  Like  all  coccidia,  it  is  an  intracellular  parasite.  It  inhabits  the 
epithelium  of  the  bile  passages  and  of  the  intestine.  Introduced  in  its 
encysted  form  (Fig.  49)  with  the  food,  the  coverings  are  dissolved  by  the 
digestive  fluids,  and  the  eight  falciform  sporozoicls  which  it  contains  are 
set  free.  These  then  probably  acquire  amceboid  properties,  and  work  their 
way  along  the  bile  ducts,  or  intestinal  canal,  finally  penetrating  the 
epithelial  cells,  where  they  grow  at  the  expense  of  the  protoplasm  of 
the  cell,  at  the  same  time  thrusting  the  nucleus  to  one  side.  Eecent 
researches  (Pfeiffer,  Simond,  Leger)  make  it  probable  that  at  this  and 
subsequent  stages  the  young  parasite  may  follow  one  or  other  of  two 
directions  in  development;  one  securing  the  multiplication  of  the  organism 
within  the  host,  the  other  directed  to  secure  the  passage  of  the  parasite 
from  one  host  to  another.. 

In  the  former  case  (endogenous  or  eimeria  form),  after  attaining  a 
certain  size,  the  little  organism  divides  into  a  number  of  segments,  each  of 
which,  on  the  bursting  of  the  including  epithelial  cell,  breaks  away,  and, 


Fig.  49. — Coccidium  oviforme,  from  the  liver  of  the  rabbit.    (  x  550.)    c-g,  stages  of 
spore-formation  only  observed  in  the  free  state. — Leuckart. 

moving  actively — possibly  as  a  flagellated  sporozoid — enters  another  epi- 
thelial cell, and  repeats  the  cycle.  In  the  second  event  (coccidial  or  exogenous 
form),  and  probably  as  an  ultimate  event  after  a  series  of  eimeria  genera- 
tions, when  the  parasite  has  attained  a  size  of  from  25  //,  to  30  p,  it  becomes 
encysted,  and,  continuing  to  grow,  assumes  an  ovoid  form  (40  ^  to  50  ^  by 
21 /a  to  28  n)  (a).  The  granular  protoplasm  now  contracts,  and  a  clear 
central  zone,  suggestive  of  a  nucleus,  is  formed  (b).  The  coccidium 
then  escapes  from  the  epithelial  cell,  and,  falling  into  the  bile  ducts  or  in- 
testine, is  carried  out  of  the  body  of  the  host  with  the  faeces.  Development 
continues  to  progress ;  the  protoplasm  divides  into  two,  then  into  four  (c,  d) 
spherical  sporoblasts,  which,  assuming  an  oval  form,  acquire  a  membranous 
covering  (spores).  Finally,  the  protoplasm  of  each  of  these  spores  divides 
into  two  nucleated  falciform  bodies  and  a  residual  body  (e,f,  g).  This  the 
extracorporeal  phase  is  now  complete,  and  becomes  infective  on  being 
transferred  to  the  stomach  of  an  appropriate  mammalian  host. 

In  the  rabbit,  aggregations  of  these  parasites  form  whitish  tumours,  the 
size  of  small  nuts,  in  the  liver,  each  tumour  including  enormous  numbers  of 
coccidia  at  all  stages  of  development.  Grave  secondary  changes  ensue, 
ending  in  dilatation  of  the  bile  ducts,  proliferation  of  the  connective  tissue, 
and  atrophy  of  the  liver  cells.  Ultimately  the  animal  suffers  from  diarrhoea, 
and,  becoming  extremely  anaemic  and  wasted,  dies  in  convulsions.  On 
vol.  i.— 34 


53° 


DISEASES  CAUSED  BY  ANIMAL  PARASITES. 


dissection,  the  liver  is  found  enlarged  and  stuffed  with  coccidial  growths, 
the  intestinal  mucosa  being  eroded  with  disseminated  coccidial  ulcerations. 

Saecospoeidia.  —  Certain    bodies,   variously   known   as   Sarcosporidia, 
psorosperm  sacs,  and,  when  occurring  in  the  muscles,  as  Miescher's  tubes 


Fig.  50. — (a)  Rainey's  tubes,  enlarged  about  40  diameters  ;  (6)  extremity  of  one 
of  Miescher's  tubes,  with  its  contents.  At  the  side  are  the  kidney-shaped 
bodies,  much  enlarged. — Leuckart. 


or  Bainey's  bodies,  are 
mouse,  deer,  and  other 
The  natural  history  and 
Several  species   have 
external  cyst  enclosing 


ft' 


frequently  present  in  the  tissues  of  the  pig,  rat, 
animals,  and  occasionally  in  those  of  man  (Fig.  50). 
significance  of  these  bodies  have  not  been  made  out. 
been  described.  They  consist  essentially  of  an 
a  vast  number  of  extremely  minute  falciform,  oval 
or  spherical  bodies,  arranged  in  groups  more  or  less 
distinct  (Fig.  50).  In  the  muscles,  a  favourite  situa- 
tion, they  may  attain  a  considerable  length — 1  mm. 
to  2  mm.  by  77  /x  to  168  p  ;  they  occupy  the  interior 
of  the  fibres.  Elsewhere,  in  the  intestine,  connective 
tissue,  heart,  kidney,  and  liver,  they  are  generally 
oval  or  round,  and  may  measure  from  20  ,a  to 
30  /j,  up  to  350  (a  in  diameter.  Kartulis  has  re- 
corded a  case  in  which  bodies  of  this  description 
gave  rise  to  fatal  abscess  of  the  liver. 

INFUSOEIA. 

Monas  pyophila. — A  flagellate  organism,  dis- 
covered by  Grimm  in  the  pus  expectorated  from  a 
liver  abscess  in  a  Japanese,  which  had  ruptured 
through  the  lung.  It  resembles  a  gigantic  spermato- 
zoid,  30  /a  to  60  //,  in  length.  In  the  case  in  question 
the  parasite  was  present  in  great  abundance. 

Plagiomonas  ieeegulaeis,  also  belonging;  to  the 
fiagellata,  is  a  pyriform  body,  10  /x  to  15  /x  in 
length,  carrying  two  flagella  on  its  larger  rounded 

end.     It  was  found  by  Salisbury  in  the  United  States,  and  by  Kunstler  at 

Bordeaux.     In  both  instances  it  was  found  in  the  urine. 


Fig.  51. — Monas  pyophila. 


Trichomonas  vaginalis  is  also  a  somewhat  similar  pyriform  organ- 
ism, 10  ^  to  15  /x  by  7  /x  to  10  //.,  with   a   very   plastic   body   carrying 


INFUSORIA. 


531 


four  flagella  springing  from  one  point  on  its  larger  and  rounded  extremity. 
From  the  same  point  an  undulating  membrane  runs  backwards  to  the  other, 
or  posterior  pointed  and  occasionally  elongated  extremity.  A  funnel- 
shaped  mouth  opens  near  the  base  of  the  flagella.  It  reproduces  by 
longitudinal  division.  It  occurs  in  unhealthy,  particul- 
arly acid,  vaginal  discharges,  and  also  in  the  bladder 
and  intestine,  more  especially  in  infantile  and  other, 
forms  of  diarrhoea.  It  has  also  been  found  in  gangrene 
of  the  lung  and  in  hydropneumothorax.  Its  patholo- 
gical bearing  is  probably  unimportant. 


Fig.  52.  —  Tricho- 
monas vaginalis. 
— After  Kolliker. 


&&?, 


Lamblia  intestinalis,  also  a  pyriform  organism 
(10  (i  to  16  ,«,,  by  5  p  or  even  12  p),  having  one  side 
of  the  larger  end  scooped  out  into  a  kind  of  sucker,  is 
provided  with  four  pairs  of  flagella ;  one  pair  springs 
from  the  anterior,  pole,  two  pairs  from  the  posterior 
margin  of  the  sucker,  and  one  pair  from  the  pointed 
posterior  extremity.  The  flagella  all  trend  backwards. 
The  parasite  can  swim  with  ease ;  its  usual  condition, 
however,  is  one  of  rest,  attached  by  its  sucker  to  the  summit  of  some 
intestinal  villus,  usually  in  the  duodenum  or  jejunum,  less  frequently  in 
the  ileum.     It  occurs  in  man;  also  in  the  cat,  dog,  sheep,  rabbit,  and 

in  several  of  the  other  smaller 
rodents.  It  multiplies  by  longi- 
tudinal division,  passing  from  one 
host  to  another  as  an  oval  encysted 
body  (10  //.to  15  /u,,  by  8  ^  to  9  //,) 
(Fig.  53),  in  which  condition  it  is 
found  in  the  large  intestines  and 
faeces.  It  is  doubtful  if  lamblia, 
though  frequently  present  in  the 
intestinal  canal  in  great  profusion, 
Fig.  53.—  Lamblia  intestinalis.  has  any  pathological  importance. 

Balantidium  coll — This  infusorian  is  of  an  oval  form,  measur- 
ing from  70  /*  to  200  /j,  in  length,  by  30  //,  to  90  ,«,  in  breadth.  It  is 
composed  of  a  finely  granular  protoplasm  enclosing  a  reniform  nucleus, 
two  contractile  vacuoles,  particles  of  fatty 
matter,  and  alimentary  debris.  The  ecto- 
plasm is  covered  with  short  cilia  subserving 
locomotion,  and  the  direction  of  food  towards 
the  funnel-shaped  indentation  or  mouth  situ- 
ated at  the  broader  end.  It  multiplies  by 
conjugation  and  fission.  This  parasite  is  not 
uncommon  in  the  caecum  and  colon  of  pigs, 
and  has  occasionally  been  found  in  man ; 
generally  it  has  been  met  with  in  association 
with  diarrhoeic  or  dysenteric  conditions,  pro- 
bably because  such  stools  are  those  which  are  most  frequently  subjected 
to  microscopical  examination.  There  is  no  sufficient  reason,  so  far  as 
known,  for  assigning  to  it  a  serious  pathological  role.  It  has  been  treated 
with  more  or  less  success  by  enemata  of  quinine,  or  of  salicylic  acid  (1  to 
1000),  and  also  by  naphthaline  by  the  mouth. 


® 


Fig.  54. — Balantidium  coli,  with 
widely  opened  peristome  (dor- 
sal view). — Leuckart. 


532 


DISEASES  CAUSED  BY  ANIMAL  PARASITES. 


ANNULOIDA. 

CESTODA. 

Zoology. — The  cestodes  or  tape-worms  are  long,  ribbon-like  animals, 
which  in  their  mature  form,  with  rare  exceptions,  inhabit  the  intestinal 
canal  of  vertebrates. 

Each  tape-worm  (Fig.  55)  consists  of  a  minute,  bulbous  head  (scolex), 
and  a  long,  flat,  and  many-jointecl  body  (strobila).     For  purposes  of  fixation, 


Fig.  55. — Tape-worm  form  of  Tcenia  saginata  s.  mediocanellata. — Leuckart. 

the  fore  part  of  the  head  is  provided  with  two  or  four  suckers,  and  gener- 
ally, though  not  always,  one  or  more  circlets  of  hooklets  surrounding  in 
some  species  a  central  proboscis  (Fig.  56).  The  strobila  or  body  is  com- 
posed of  joints  {proglottides),  which  are  developed  serially  and  continuously 
from  the  posterior  part  of  the  head.     Each  joint  contains  male  and  female 


Z*  / 


'•  -   ■  I 


Fig.  56. — (a)  Apex  and  hooks  of  T.  solium  ;  (b)  head  of  T.  solium. 
(x  35.) — Leuckart. 

sexual  organs  (hermaphrodite) ;  to  this  extent,  although  articulated  to 
the  joints  before  and  behind,  it  is  a  complete  and  independent  animal 
in  itself.  The  young  proglottides  or  joints — that  is,  those  nearest  the 
head — are  immature,  and  generally  very  minute ;  in  some  instances 
almost  thread-like.     As  the  joints  become  older,  and   therefore   further 


CESTODA. 


533 


down  the  strobila,  they  become  progressively  broader,  longer,  thicker,  and 
sexually  more  mature.  Thus  a  tape-worm  is  broad  at  one  end,  the 
posterior,  that  is  where  the  segments  are  mature,  and  almost  filiform  at 
the  other — the  head  or  immature  end.  There  is  no  mouth  and  no 
alimentary  canal,  nourishment  being  derived  by  absorption  from  the 
alimentary  juices  in  the  intestine  of  the  host.  The  rudimentary  nervous 
and  excretory  systems  are  continuous  throughout  the  entire  length  of  the 
parasite. 

As  the  terminal  joints  mature  they  break  away  singly  or  in  strings, 
escaping  spontaneously,  or  being  expelled  in  the  dung  of  the  host.  The 
ova  contained  in  the  now  free  proglottides  escape  in  various  ways,  and,  if 
fortune  favour,  finally  enter  a  suitable  intermediate  host.  The  medium  in 
which  the  ovum  gets  access  to  its  special  intermediate  host  differs  in 
different  species.  In  some  species  the  ova  are  poured  out  on  the  ground ;  in 
others  they  find  their  way  into  water ;  in  others,  again,  they  are  conveyed 
in  food.  In  some  they  enter  the  stomach  of  the  intermediate  host  whilst 
still  in  the  proglottis.  By  the  action  of  the  digestive  juices  of  the  inter- 
mediate  host  the   shell  of   the  ovum  is  dissolved   off,   and   the  minute, 


Fig.  57. — Embryo  containing  egg  (a)  of 
T.  solium  (without  yolk  skin)  ;  (b) 
of  T.  nymphaea.  (  x  400.) — Leuck- 
art. 


3    b 


Fig.  58.— (a)  The  common  bladder  ■worm  of  the 
pig  with  invaginated  head  (  x  ^) ;  (6)  the 
same,  with  evaginated  head  ( x  2). — 
Leuckart. 


six-hooked  embryo  which  each  ovum  contains  is  liberated  (Fig.  57).  The 
embryo  thus  freed  works  its  way  into  the  vessels  and  tissues  of  the  inter- 
mediate host,  and  finally  comes  to  rest  in  some  appropriate  tissue  or 
organ.  Herein  it  undergoes  a  somewhat  complicated  metamorphosis,  in  the 
course  of  which  the  six  booklets  are  got  rid  of,  and  the  embryo  in  most 
instances  acquires  a  cystic  structure  {Cysticercus,  Hydatid).  Finally,  at 
that  pole  of  the  embryo  which  is  opposite  to  that  previously  occupied  by 
the  six  hooklets,  one  or,  as  in  the  hydatid-forming  tape-worms,  many 
scolices  or  heads,  exactly  like  the  head  of  the  parent  tape-worm,  are 
developed  (Fig.  58).  In  this  condition  the  parasite  may  remain  encysted 
for  a  considerable  time.  If  now  the  intermediate  host  be  eaten  by  an 
appropriate  vertebrate,  the  scolex  or  scolices  are  set  free,  and,  attaching 
themselves  by  the  suckers  and  hooklets,  with  which  they  are  provided,  to 
the  mucous  surface  of  the  intestine  of  the  definitive  host,  rapidly  grow  into 
tape-worms.  In  one  family  of  tape-worms,  fiothriocejohahis,  there  is  no 
cystic  formation  in  the  intermediate  host,  the  larva  lying  free  in  the 
tissues. 

About    a    dozen   species   of   tape-worms   have   been   found   in    man. 
Only  three  of  these,  Tcenia  mediocanellata,  Tccnia  solium,  and  Bothriocephcdus, 


534 


DISEASES  CA  USED  BY  ANIMAL  PARASITES. 


are    proper   to   him,   or,   from    their    frequency,   possess    much   clinical 
importance. 

T.  mediocanellata  (T.  saginata)  is  sometimes  designated  the 
beef  tape-worm,  from  the  circumstances  that  its  immature  or  cystic 
stage  is  passed  in  the  muscles  of  the  ox.  "When  mature,  this  parasite 
measures  from  4  to  10  metres  in  length.  It  is  made  up  of  some  1200  to 
1500  proglottides  or  joints,  the  terminal  or  more  mature  of  which  have  a 
length  of  from  15  to  20  mm.,  and  a  breadth  of  from  6  to  8  mm.     The 


Fig.  59. — Head  of  Taenia  saginata  in  contracted  (a)  and 
extended  condition  (b).     (x  8.) — Leuckart. 


proglottides  at  the  centre  of  the  strobila  are  the  broadest.  Traced 
upwards,  they  gradually  fine  down  to  a  very  narrow  and  delicate  ribbon, 
which  terminates  in  a  pear-shaped  head,  provided  with  four  suckers 
(Fig.  59).  There  are  no  hooklets  on  the  head ;  hence  the  name,  T.  inermis, 
occasionally  given  to  this  tape-worm.  The  genital  pores  open  on  the 
margin  of  the  proglottides,  and  can  usually  be  readily  seen. 

T.  mediocanellata  is  conveyed  to  man  in  raw  or  imperfectly  cooked, 
measly  beef  (Fig.  59),  that  is,  beef  containing  the  "  measle  "  or  cysticercus. 
After  the  cystic  portion  of  the  cysticercus  is  dissolved 
off  in  the  stomach  of  the  human  host,  the  head  attaches 
itself  to  the  mucous  membrane.  The  worm  now  grows 
so  rapidly  that  in  two  months  it  attains  maturity. 
It  then  begins  to  give  off  dailv,  and  for  an  indefinite 
number  of  years,  some  eight  to  twelve  ripe  proglottides, 
each  of  them  crowded  with  ova  (38  by  30  ,«.)  having  a 
thick  striated  shell,  and  containing  a  minute  six-hooked 
embryo.  The  proglottides,  on  escaping  (usually  singly) 
from  the  bowel,  spontaneously  or  in  the  fa?ces,  creep 
about  on  the  ground  or  in  the  clothes,  forcing  out  their 
ova,  often  through  a  rent,  as  they  contract.  The  ova 
thus  get  scattered  about  on  the  grass  or  elsewhere,  and 
so  obtain,  perhaps,  an  opportunity  of  attaining  their  appropriate  inter- 
mediate host,  the  ox,  in  the  connective  tissue  of  whose  muscles  and  viscera 
they  assume  their  cysticercus  form. 

T.  mediocanellata  is  found  wherever  oxen  are  kept,  more  especially 
where  the  cattle  are  badly  tended,  where  beef  is  eaten  raw  or  imperfectly 
cooked,  and  where  the  habits  of  the  people  expose  their  cattle  to  the 
infection. 


Fig.  60. — Cysticercus 
tcenice  saginatce, 
embedded  in  the 
muscle.  (Xat.  size.) 
— Leuckart. 


CESTODA. 


535 


T.  solium,  or  the  pork  tape-worm,  measures  usually  about  3  metres, 
sometimes  6  or  8  metres,  in  length.  The  proglottides  number  about  850 
in  an  ordinary  specimen ;  those  about  the  middle  of  the  worm  attaining  a 
breadth  of  8  mm.,  the  narrower  but  more  elongated  terminal  joints  being 
from  10  to  12  mm.  in  length  by  5  mm.  in  breadth.  The  head  (Fig.  56), 
which  is  furnished  with  four  suckers,  is  readily  distinguished  from  that  of 
T.  mediocanellata  by  the  double  row  of  twenty-six  to  twenty-eight  hooklets 
which  surround  the  somewhat  prominent  rostellum.  The  genital  pores 
open  marginally.  As  in  T.  mediocanellata,  the  uterus  consists  of  a  longi- 
tudinal trunk  with  lateral 
branches ;  but  whereas  in 
T.  mediocanellata  these 
branches  are  straight,  and 
do  not  subdivide,  in  T. 
solium  they  ramify  dendri- 
tically.  The  ovum  of  T. 
solium  is  almost  round, 
measuring  30  /i  to  35  p\ 
the  thick  striated  shell 
encloses  a  six -hooked  em- 
bryo. 

The  cystic  phase  of  this 
tape-worm  is  usually  found  in  the  pig ;  but  it  occurs  also  in  many  other 
mammals,  including  man.  It  is  known  as  Cysticercus  celhdosce,  and 
occurs  in  the  connective  tissue  of  the  muscles  and  viscera  and  elsewhere 
(Tig.  61).  It  forms  an  ellipsoidal  vesicle,  6  to  10  mm.  in  length,  varying 
in  size  a  good  deal,  according  to  the  amount  of  pressure  it  is  subjected  to. 
In  man,  besides  in  the  muscles,  it  is  met  with  in  the  eye,  which  it 
may  destroy;  in  the  brain,  as  a  peculiar  ramifying  cyst  (C.  racemosus), 
causing  in  many  instances  a  variety  of  nervous  symptoms ;  and  in 
manv  of  the  other  viscera,  including  the  heart.     When  it  lies  under  the 


Fig.  61. — Measly  pork.     (Xat.  size.) — Leuckart. 


,s«a3E»»Mi|g||g  ilfllll 


■■  ifliiiii  wpiteisi 


Fig.  62. — BotTiriocephalus  lotus. — Leuckart. 

skin  it   forms  little  pea-shaped  swellings,  whose  nature  is  often  unsus- 
pected till  they  are  excised  and  carefully  examined. 

T.  solium  is  usually  contracted  from  eating  raw  or  underdone  pork. 
The  dirty  habits  of  the  pig  afford  a  ready  explanation  of  its  special  prone- 
ness  to  C.  cellulosce  infection. 

Bothpjocephalus  latus,  or  the  fish  tape-worm,  attains  a  great  length,  6 
to  10  metres,  sometimes  even  16  metres  (Fig.  62).  It  is  also  remarkable  for 
its  great  breadth  (10  to  12  mm.),  and  for  the  relative  shortness  of  the 
proglottides  (4  to  5  mm.),  which  in  a  full-grown  specimen  number  from 
3000  to  4000.     The  terminal  segments  are  narrower  and  longer  than  those 


DISEASES  CA  USED  BY  ANIMAL  PARASITES. 


higher  up  the  strobila,  and  are  furnished  with  two  well  marked,  laterally 
placed,  suctorial  grooves.  The  head  of  the  worm  is  flattened  and  club- 
shaped.  The  uterus  when  distended  with  ova  is  thrown  into 
a  series  of  radially  arranged  folds,  forming  what  is  known 
as  the  uterine  rosette,  towards  the  forepart  of  which, 
on  the  flat  surface  of  the  worm,  are  placed  in  close  ap- 
position the  male  and  female  openings.  The  ova,  68  p 
by  45  >m,  are  brown,  thick-shelled,  ellipsoid,  and  oper- 
culated.  The  six-hooked  embryo  is  not  developed  until 
the  ovum  has  been  in  water  for  some  weeks  or  months, 
according  to  temperature.  When  ripe,  it  forces  back  the 
operculum,  and  becomes  a  free,  swimming  animalcule, 
moving  about  by  means  of  the  innumerable  and  very  long 
cilia  with  which  it  is  covered.  On  being  swallowed  by 
shaped  head  of  certain  kinds  of  freshwater  fish — pike,  burbot,  perch,  trout, 
Seen  from  the  e^c- — ^  penetrates  their  muscles,  and  develops  into  a 
ribbon-shaped  larva,  8  to  30  mm.  in  length.  This  is 
virtually  the  head  and  neck  of  the  future  bothriocephalus. 
It  lies  unencysted  between  the  muscular  fibres  of  the 
intermediate  host.  Unlike  the  other  tape-worms,  the 
larval  bothriocephalus  has  no  cysticercus  form.  On  being  swallowed 
by  man,  or  by  some  animal,  as  the  dog  or  cat,  it  grows  into  a  mature 
tape-worm. 

The  geographical  distribution  of  B.  latus  is  somewhat 
restricted,  being  influenced,  doubtless,  by  the  ichthyophagus 
habits  of  the  inhabitants  of  special  districts.  It  is  found 
principally  on  the  shores  of  the  Baltic,  around  the  Swiss  „ 
lakes,  in  North  Italy,  Bavaria,  Poland,  Turkestan,  Japan,  ^f  %~  ^™ 
and  recently  on  the  banks  of  Lake  Nganii,  South  Africa,  with  yolk  cells 
In  some  of  these  places  a  very  large  proportion  of  the  in-  fu^  R(^!\e11 
habitants  are  affected. 


Fig.    63.  —  Club- 


flat  edge  ;  (b) 
from  the  sur- 
face, (x  8.) 
— Leuckart. 


(  x     300.)   — 
Leuckart. 


T.  nana. — The   foregoing  tape-worms  are  normally  parasitic  in  and 
proper    to    man.      Besides    these,   however,   certain    tape-worms,   whose 
normal  habitat  is  in  some  of  the  lower  animals  more  or  less  intimately 
associated   with   man,  occasionally  find  their  way  into   the   human  ali- 
mentary canal,  and  there  develop  and  attain  maturity. 
\)  The  best  known  of  these   is  T.  nana  (Fig.  66),  which 

fa  a  is  believed  to  be  identical  with  T.  marina  of  the  rat, 
and  which  has  frequently  been  found  in  man,  especially 
in  children,  in  certain  warm  countries,  including  Egypt, 
Servia,  Italy,  Sicily,  the  United  States,  Brazil,  Siam,  etc. 
It  is  a  very  minute  cestode,  12  to  2CF  mm.  in  length  by 
0-5  mm.  in  breadth,  and  with  about  150  joints. 

The  head  is  spherical,  and  carries  a  rounded  retractile 
and  prominent  rostellum,  surrounded  by  a  single  row  of 
twenty-two  to  twenty-eight  minute  hooklets. 


Fig. 
B, 


65. — Larvae  of 
latus  from  the 
pike,  (a)  and  (6) 
with  extended,  (c) 
with  contracted 
head,  (a)  nat.  size, 
(b)  and  (c)  x  3.— 
Leuckart. 


T.  flayopunctata  is  another,  but  rarer,  visitor  to  man. 
It  is  also  supposed  to  be  normal  to  the  rat,  in  which 
it  is  known  as  T.  leptocejjhala.  It  measures  from  20  to 
40  cms.  in  length,  the  ripe  proglottides  being  about  3*5 
mm.    in    breadth    and    proportionately   very   short,   but 


CESTODA. 


537 


becoming  longer  and  narrower  posteriorly.  The  proglottides  towards  the 
forepart  of  the  strobila  are  characterised  by  a  yellow  spot,  the  distended 
receptaculum  seminis.  The  ova,  0*06  mm.,  are  smooth,  have  a  double 
outline,  and  enclose  a  six-hooked  embryo.  The  head  is  without  hooks,  and 
carries  four  suckers. 

T.  madagascaeiensis  is  another  tape- worm  which  of  late  years  has  been 
found  in  man  some  eight  times,  and  in  countries  very  far  apart — in 
Mayotte,    Mauritius,   Siam,   and  British    Guiana.      The   larval    form  is 


Fig.  66. — Taenia  nana. — Leuckart. 

believed  by  Blanchard  to  occur  in  some  insect ;  he  suggests  the  cockroach. 
The  mature  worm  is  from  25  to  30  cms.  long,  having  some  six  hundred 
joints,  which  are  considerably  broader  than  they  are  long.  The  head 
carries  a  rostellum  surrounded  by  a  double  circle  of  hooklets.  The  four 
suckers  are  round  and  large.  The  sexual  opening  is  marginal.  The 
normal  host  of  this  tape- worm  is  unknown ;  it  is  supposed  to  be  a  bird. 

B.  mansoni. — This  is  the  larval  form  of  a  bothriocephalus  whose 
mature  form  is  proper  probably  to  some  carnivorous  animal.  It  is 
a  long  ribbon-shaped  organism,  364  mm.  by  12  mm.  The  writer  found 
many  specimens  of  this  parasite  in  the  subperitoneal  connective  tissue 
of  a  Chinese  ;  Baelz  also  extracted  one  from  the  urethra  of  a  Japanese.  A 
similar,  or  an  identical,  parasite  has  lately  been  met  with  by  Daniels  in 
a  G-uiana  Indian. 


Besides  these,  other  cestodes  have  occasionally  been  found  in  man; 
they  are  so  rare,  however,  that  they  cannot  be  said  to  have  any  patho- 
logical importance  or  to  be  more  than  curiosities. 

Symptoms. — Apart  from  the  appearance  of  proglottides  in  the 
stools,  in  many  instances  the  presence  of  a  tape-worm  gives  rise  to  no 
symptoms  whatever.  On  the  other  hand,  these  parasites  at  times  seem 
to  be  associated  with  abdominal  discomfort,  dyspepsia,  colicky  pains, 
diarrhoea  alternating  with  constipation,  capricious  appetite,  foul  breath, 
and  so  forth.  In  yet  other  cases  a  variety  of  nervous  symptoms,  including 
epileptiform  seizures  and  even  mental  aberration,  may  result  apparently 
from  the  presence  of  a  tape-worm.  In  a  proportion  of  instances,  particu- 
larly in  bothriocephalus  infection,  there  is  developed  a  peculiar  form  of 
hemolytic  anaemia,  in  some  cases  of  a  profound  character,  bothriocephalus 
anaemia. 

Diagnosis. — The  diagnosis  of  the  particular  species  of  tape-worm  pre- 
sent in  any  given  case  may  be  arrived  at  by  a  careful  examination  of  the 
proglottides.  B.  latus  is  at  once  recognised  by  the  breadth  of  the  proglot- 
tides and  by  the  position  of  the  sexual  openings  on  the  surface  of  the 
proglottis.     In  both  T.  solium  and  T.  mccliocanellata  the  sexual  opening  is 


538 


DISEASES  CA  USED  BY  ANIMAL  PARASITES. 


marginal ;  but  in  the  former  the  lateral  branches  of  the  uterus  are  arranged 
dendriticallv,  whereas  in  T.  mediocanellata  thev  are  straight. 

Treatment. — For  a  few  days  before  instituting  specific  anthelmintic 
treatment,  it  is  advisable  to  endeavour  to  get  rid  of  any  mucus  that  may 
be  covering  the  parasite  to  be  attacked.  A  light  diet,  and  a  few  doses  of 
sulphate  of  soda,  will  generally  suffice  for  this.  On  the  night  before  the 
anthelmintic  is  administered,  the  patient  should  go  to  bed  fasting,  or  with 
only  a  cup  of  milk  for  the  evening  meal.  The  drug  selected  is  best  given 
in  the  early  morning,  and  on  an  empty  stomach.  Male  fern  is  the 
anthelmintic  principally  relied  on ;  if  properly  administered,  it  is  usually 
successful.  It  is  •  best  given  in  emulsion,  or  in  milk,  in  doses  of  half  a 
drachm  at  a  time,  and  repeated  every  half -hour  for  four  times,  the  last 
dose  being  followed  by  a  smart  cathartic.  Kousso,  if  the  drug  is  quite 
fresh,  is  also  a  good  anthelmintic.  The  dose  is  from  4  to  6  oz.  of  the 
official  infusion.  Pomegranate  decoction  (2  oz.  of  bark  to  the  pint  of 
water),  6  oz.  three  times  in  succession  at  intervals  of  half  an  hour,  is 
often  effective.  Its  alkaloid,  pelletierine,  in  from  5  to  7  grs.,  is  said  to  be 
very  reliable  ;  it  is  somewhat  intoxicating,  and  therefore  not  quite  safe  for 
children.  The  dose  of  turpentine,  formerly  much  in  vogue  in  the  treat- 
ment of  tape-worm,  though  now  rarely  used,  is  from  2  to  4  drms.  in 
capsules  or  emulsion.  For  young  children  the  safest,  and  a  very  effective, 
anthelmintic  is  bruised  pumpkin  seeds ;  the  dose  is  an  ounce  made  up  as 
an  electuary. 

It  is  well  for  the  patient  to  remain  lying  down  until  the  intoxicating 
effects  of  these  drugs,  in  some  instances  very  pronounced,  have  passed 
away,  and  until  the  bowels  have  been  freely  moved  by  a  cathartic.  After 
the  operation  of  the  latter,  search  should  be  made  in  the  stools  for  the 
head  of  the  worm ;  unless  this  is  found,  no  matter  though  yards  of  pro- 
glottides have  been  passed,  there  can  be  no  assurance  that  this,  the  most 
important  part  of  the  parasite,  has  been  got  rid  of,  or  that  proglottides  will 
not  reappear  in  the  stools  some  six  weeks  later. 

TEEMATODA. 

Zoology. — These,  with  one  exception  (Bilharzia  hcematohia),  are  flat, 
fluke-shaped,  hermaphrodite  parasites  (Fig.  67).    They  possess  two  suckers, 


Fig.  67. — Distomum  hepaticum.     (Magnified.) 


an  anterior  or  oral  placed  at  one  extremity  of  the  oval  body,  and  a  posterior 
or  ventral  placed  on  the  ventral  surface  behind  the  former,  and  generally 
in  the  neighbourhood  of  the  sexual  opening.  The  alimentary  canal  opens 
at   the   anterior   or   oral   sucker.     The   simple   mouth   leads   to  a   short 


TREMATODA. 


539 


oesophagus  which  divides,  the  two  branches  coursing  along  the  lateral 
borders,  one  on  each  side,  and  terminating  Ciecally  near  the  posterior  end 
of  the  parasite.  An  excretory  system  of  vessels  unites  into  a  single  trunk 
which  opens  posteriorly.  The  greater  part  of  the  worm  is  occupied  by 
the  male  and  female  organs. 

Those  distomes  which  inhabit  man  are  all  of  them  oviparous.  The 
eggs,  carried  out  of  the  body  of  their  human  host  in  the  excreta  or  in 
morbid  discharges,  find  their  way  into  water,  where  in  due  course  a  ciliated 
embryo  escapes,  and  swims  about  seeking  out  its  appropriate  intermediate 
host.  The  latter  is  usually  some  fresh  water  mollusc  or  arthropod.  This 
the  embryo  contrives  to  enter,  and  therein,  after"  getting  rid  of  its  ciliated 
covering,  becomes  converted  into  a  sporocyst  (Fig.  68),  or  into  a  somewhat 
similar  structure  called  a 
rcdia.      The   redia   differs  ° 

from  a  sporocyst  in  being 
provided  with  a  rudiment- 
ary mouth  and  alimentary 
canal.  In  due  course  cer- 
tain germ  cells  in  these 
sporocysts  or,  it  may  be, 
redia?,  evolve  into  what 
are  known  as  cercarice — 
minute  tailed  organisms 
with  rudimentary  suckers 
like  those  of  the  future 
fluke.  In  time  the  cercaripe 
escape  from  the  inter- 
mediate host,  and  either 
enter  a  second  animal,  or 
attach  themselves  to  some 
vegetable,  and  become  en- 
cysted. If  the  cercarise 
are  now  swallowed  by  the 
appropriate  definitive  host,  FlG  6g  _ge(jife 
they  develop  into  mature  interior 

distomes. 

Distomum  hepaticum. — Though  proper  to  the  sheep,  D.  hepedicum  is 
sometimes  found  in  other  animals,  and  also,  though  rarely,  in  man.  Its 
normal  habitat  is  the  bile  ducts  ;  these  it  dilates  and  thickens,  giving  rise 
at  the  same  time  to  enlargement  of  the  liver,  vomiting,  diarrhoea,  ascites, 
jaundice,  emaciation,  and  fever,  and  in  many  instances  leading  to  death. 
The  parasite  is  known  as  the  "  liver  fluke,"  and  the  disease  in  sheep  as 
"  rot." 

D.  hepaticum  is  long,  brown,  leathery,  flat,  leaf -shaped,  broader 
anteriorly  than  posteriorly,  and  covered  with  minute  spines  directed 
backwards.  It  measures  from  15  to  30  mm.  in  length  by  4  to  13  mm.  in 
breadth.  The  ventral  sucker  lies  close  behind  the  oral,  which  is  placed  at 
the  free  extremity  of  a  sort  of  beak-like  protuberance.  The  large,  brown, 
operculated  eggs  (0*13  mm.  by  0*08  mm.)  escape  in  the  bile  and  faeces. 
On  being  hatched  out,  the  embryo  enters  the  body  of  a  certain  fresh  water 
gastropod  mollusc  (Limnma  truncattda  and  allied  species),  in  which,  from 
sporocyst  and  rediee,  the  cercariae  are  ultimately  developed.  The  latter 
escaping,  or  perhaps  while  still  in  the  mollusc,  are  passively  transferred  in 


(a)  with  germs  ;  (b)  with  cercarice  in  the 
;  (c)  free  cercarice. — Leuckart. 


54° 


DISEASES  CA  USED  BY  ANIMAL  PARASITES. 


grass  or  water  to  the  stomach  of  the  sheep,  or  it  may  be  to  that  of  man. 
Thence  they  find  their  way  into  the  bile  ducts,  where  they  ultimately 
develop  into  the  mature  parasite,  setting  up  the  morbid  changes  referred 
to.     Should  they  happen  to  be  present  in  sufficient  numbers  in  the  human 

subject,  doubtless  they  would  give  rise  to  a 
dangerous  disease  similar  to  "  rot "  in  sheep. 

D.  lanceolatum  has  been  found  some  five 
times  in  the  bile  ducts  of  man.  Owing  to  its 
smaller  size,  it  is  not  so  formidable  a  parasite 
as  the  preceding.  It  measures  8  to  10  mm. 
in  length  by  2  to  24  mm.  in  breadth,  the 
broadest  part  being  posteriorly.  It  is  further 
distinguished  from  D.  hepaticum  by  its  thin- 
ness, suppleness,  and  absence  of  cuticular 
spines.  The  ova  (0'04  by  O03  mm.)  are 
dark,  double  outlined,  operculated,  and  con- 
tain a  ciliated  embryo,  the  intermediate  host 
of  which  is  supposed  to  be  Planorois  mar- 
ginatum. 

D.  conjunctum,  apparently  a  parasite  of 
the  Indian  pariah  dog,  has  been  reported  as 
occurring  in  the  dilated  bile  ducts  of  man. 
It  measures  9-5  mm.  by  2-5  mm.,  and  is 
covered  with  minute  spines.  The  ova  (0-034 
by  0*021  mm.)  are  double  outlined  and  oper- 
culated. 

D.  sinense  is  not  very  uncommon  in 
natives  of  Japan  and  China,  and  has  also 
been  found  in  East  Indians.  In  some  in- 
stances of  high  degrees  of  infection  it  has 
proved  a  formidable  parasite,  giving  rise  to 
dilatation  of  the  bile  ducts,  enlargement  of  the  liver,  and  a  cachexia 
corresponding  to  that  of  sheep  rot,  and  characterised  by  fever,  diarrhoea, 
anasniia,  and  dropsy,  terminating  after  a  time  in  death.  The  parasite 
measures  18  by  4  mm.,  and  is  readily  distinguished  from  D.  conjunctum  by 
the  complete  absence  of  cuticular  spines. 
The  ova  (0-03  by  0-016  mm.)  are  granu- 
lar, double  outlined,  and  operculated. 

D.  ceassum  is  the  largest  of  the 
distomes  occurring  in  man.  It  mea- 
sures 4  to  7  cms.  in  length  by  17  to 
2  cms.  in  breadth.     It  has  been  found  .     .—   .    us   .    (i  a  .  size.) 

in  China,  Borneo,  the  Malay  Peninsula,  India,  and  British  Guiana.  It  is 
oblong  in  shape,  fleshy,  brown,  and  devoid  of  cuticular  spines  ;  it  may  be 
further  identified  by  the  close  approximation  of  the  oral  and  ventral 
suckers.  The  ova  (0125  by  0-075  mm.)  possess  granular  contents  enclosed 
in  a  very  delicate  operculated  shell.  The  habitat  of  this  parasite  is  the 
alimentary  canal;  possibly  it  is  responsible  for  the  dyspeptic  symptoms 
and  diarrhoea  with  which  it  has  been  found  associated. 


Fig.  69. — Distomurn  sinense. 


TREMATODA. 


54i 


D.  hetbkophyes,  an  exceedingly  minute  (1-15  by  0*7  mm.)  distome  with 
a  proportionately  very  large  ventral  sucker,  occurs  in  man  in  Egypt. 
The  ova  (0-026  by  0-01  mm.)  are  reddish  brown,  and  communicate  their 
colour  to  the  parasite.  D.  heterophyes  lives  in  the  small  intestine. 
Apparently  it  gives  rise  to  no  morbid  symptoms. 

D,  eingeri  {D.  pulmonale,  D.  westermanni)  (Fig.  71),  a  very  thick, 
fleshy  distome,  8  to  10  mm.  by  5  to  6  mm.,  having  a  double  outlined 
operculated  ovum  (0-08  by  0*1  mm.),  inhabits  the  lungs  of  man  and  certain 
carnivora  in  Japan,  Corea,  China,  and  the  Island  of  Formosa.  It  lives  in 
tunnels  connected  with  the  bronchi.  Into  these  bronchi  the  ova  are  poured, 
escaping  thence  in  the  sputum.  After  passing  some  weeks  in  fresh  water, 
a  ciliated  embryo  is  developed,  which  at  maturity,  by  forcing  back  the 
operculum  of  the  shell,  escapes  and  swims  about  in  the  water.  Nothing 
further  of  its  life-history  is  known. 

Symptoms, — D.  ringeri  gives  rise  to  what  at  times  is  a  formidable 
kind  of  haemoptysis.     Patients   in  whose  luugs  this  parasite  occurs  are 


Fig.  71. — D.  ringeri. — Leuckart. 


^ — .  L?:.  fr,  •  ••  ..V'  »^  *>.-*.•*.- 
Fig.  72. — Ova  of  D.  ringeri  in  sputum. 


affected  with  a  chronic  cough  and  peculiar  brown,  viscid,  pneumonic-like 
expectoration,  in  which  the  microscope  discovers  myriads  of  the  charac- 
teristic ova  (Fig.  7^).  In  addition  to  the  cough  and  expectoration,  which 
are  a  permanent  feature,  the  patient  is  liable  to  occasional  attacks  of 
sudden  haemoptysis.  This  may  be  so  profuse  as  to  lead  to  pronounced 
anaemia,  and  even  to  endanger  life.  Furthermore,  high  degrees  of 
infection  may  end  in  extensive  fibrotic  changes  in  the  lungs,  and  may, 
by  predisposing  to  other  forms  of  lung  disease,  indirectly  prove  fatal. 
This  parasite  has  also  been  found  in  the  cortex  of  the  brain,  where, 
from  the  irritation  and  pressure  produced  by  the  exudation  it  creates 
around  it,  it  may- give  rise  to  a  variety  of  cerebral  symptoms,  including 
Jacksonian  epilepsy,  which  sooner  or  later  terminate  in  death.  D.  ringeri 
has  also  been  found  in  the  testes,  and  in  the  peritoneum. 

Amphistomum  hominis  has  been  found  in  India  inhabiting  the  caecum, 
appendix,  and  ascending  colon,  to  the  mucous  membrane  of  which  it 
attaches  itself  by  the  relatively  enormous  ventral  sucker.  It  is  a  minute 
parasite,  measuring  5  to  8  mm.  by  3  to  4  mm.  The  ventral  sucker 
referred   to  is   placed   at    the    extreme   posterior   end,  and  is  the  most 


542 


DISEASES  CAUSED  BY  ANIMAL  PARASITES. 


prominent  and  characteristic  feature  about  the  worm.  The  ova  measure 
0*15  by  0-07  mm.,  and  are  operculated.  Apparently  this  parasite  is  of  no 
pathological  importance. 

Bilharzia  HiEMATOBlA  (D.  haematobium).  This  important  parasite 
is  confined  to  Africa  and  its  island  dependencies,  including  Mauritius, 
to  Arabia,  and  to  a  limited  district  in  Persia.  It  is  particularly  prevalent 
in  Egypt,  and  has  often  been  found  in  Europeans  who  have  visited  that 
country.  It  occurs  in  certain  districts  in  Tunis,  in  the  Sahara,  in  South 
Africa,  and  on  the  West  Coast.  It  gives  rise  to  the  disease  known  as 
"  bilharzia  disease,"  or  "  endemic  hematuria." 

Unlike  the  other  distomes  affecting  man,  Bilharzia  hceinatdbia  is 
bisexual,  the  female — a  long  (20  mm.)  filiform  animal — being  partially 
enclosed  in  a  gynsecophoric  canal  produced  by  the  infolding  of  the  lateral 
borders  of  the  shorter  (15  by  1  mm.),  stouter,  and  cylindroid  male  worm. 
The  normal  habitat  of  Bilharzia  is  the  portal  veins  and  its  branches, 
where,  by  careful  search,  it  may  be  found  in  considerable  numbers  (up  to 
300,  Kartulis). 

The  ova  (Fig.  74,  a),  which   are  minute  (0-16  by  0-06  mm.),  brown 


llif 


Fig.  73. — D.  hcematobium,  male  and  female,  the  latter 
in  the  canalis  gynsecophorus  of  the  former.— 
Leuckart. 


Fig.  74. — (a)  Ovum,  and  (b)  free  embryo 
of  Bilharzia. 


bodies,  provided  with  a  very  characteristic  terminal  spine,  but  without 
operculum,  contain  a  ciliated  embryo.  They  escape  into  the  outer  world 
in  the  urine  and  also  in  the  feeces  of  the  host.  When  urine  contain- 
ing these  ova  is  mixed  with  water,  the  embryo  (Fig.  74,  b)  escapes  from 
the  egg  through  a  longitudinal  rupture  in  the  shell,  and  swims  about. 
Nothing  definite  is  known  as  to  its  intermediate  host,  nor  as  to  its  future 
life  history. 

The  exact  process  by  which  the  ova  of  Bilharzia  contrive  to  get  out  of 
the  human  body  has  not  been  satisfactorily  explained.  Apparently  the 
gravid  female  seeks  out  the  venous  radicles  in  the  rectum  and  bladder, 
and  there  deposits  her  eggs,  which  subsequently  work  their  way,  possibly 
aided  by  the  spine  with  which  they  are  provided,  into  bladder  and 
bowel. 

In  consequence  of  the  presence  of  vast  numbers  of  ova,  and  the 
attendant  irritation  to  which  they  give  rise,  the  walls  of  the  bladder 
become  thickened  and  the  mucous  membrane  inflamed,  roughened,  and, 
occasionally,  the  seat  of  phosphatic  deposit,  the  entire  organ  undergoing 
all  the  morbid  alterations  incident  to  chronic  cystitis.  The  ureters, 
vesiculae  seminalis,  uterus,  and  even  the  pelvis  of  the  kidney  may  be 
affected.     Sometimes  the  ova  form   the   nucleus  of   urinary  calculi.     In 


TREMATODA.  543 

the  rectum,  a  chronic  proctitis  may  be  established  by  the  presence  of 
the  parasite  or  of  its  ova,  and  minute  polypoid  growths  arise  in  con- 
sequence. 

Symptoms. — As  a  general  rule,  Bilharzia,  beyond  giving  rise  to  a 
slight  degree  of  urinary  irritation  and  hematuria,  is  not  a  very  trouble- 
some parasite.  Occasionally,  however,  in  consequence  of  the  chronic- 
cystitis  it  induces,  bilharzia  infection  is  attended  with  much  suffering,  and, 
by  causing  secondary  changes  in  the  kidneys,  or  stone  in  the  bladder,  may 
even  endanger  life.  In  some  of  the  endemic  districts,  particularly  Egypt, 
owing  to  the  frequency  of  the  infection,  the  aggregate  amount  of  suffer- 
ing and  the  severe  disease  it  induces,  bilharzia  infection  becomes  a  serious 
matter. 

From  implication  of  the  rectum,  a  sort  of  false  dysentery  is  frequently 
present ;  but  in  the  vast  majority  of  cases  the  leading  symptoms  are  to  be 
referred  to  the  bladder.  In  slight  degrees  of  the  infection  the  patient  is 
conscious  of  a  feeling  of  urinary  irritation,  most  pronounced  at  the  end  of 
micturition,  the  passage  of  the  last  few  drops  of  blood-tinged  urine  being 
attended  with  a  sense  of  heat.  In  more  severe  infections,  especially 
during  exacerbations  of  the  attendant  cystitis,  the  suffering  is  very  great, 
resembling  that  in  stone.  The  desire  to  micturate  is  almost  incessant, 
and  the  urine  (ammoniacal,  perhaps)  is  loaded  with  muco-pus,  some- 
times containing  much  blood.  Ultimately  a  continuance  of  suffering 
may  wear  out  the  patient,  or  secondary  kidney  affection  may  prove 
fatal. 

On  holding  the  urine  of  a  bilharzia  patient  up  to  the  light,  ib  is  seen 
to  contain  numerous  little  white  shreds  or  strings  of  mucus.  These  under 
the  microscope  are  found  to  be  studded  with  the  characteristic  brown,, 
spined  ova.  If  such  urine  be  allowed  to  stand,  on  sampling  the  sediment, 
ova  can  be  readily  detected.  In  mild  infections,  the  best  plan  of  find- 
ing the  ova  is  to  catch  in  a  watch-glass  the  last  few  drops  of  urine 
while  the  patient  strains ;  this  almost  invariably  contains  an  abundant 
supply.  Bilharzia  once  contracted  is  rarely  got  rid  of.  The  cystitis  it 
gives  rise  to  and  the  presence  of  ova  in  the  urine,  may  persist  for 
twenty  or  even  thirty  years. 

Diagnosis. — The  presence  of  the  various  trematodes  above  de- 
scribed, although  it  may  be  suspected,  cannot  be  affirmed  with  certainty 
unless  the  parasites  themselves  or  their  ova  are  found  in  faeces,  urine,  or 
sputum,  as  the  case  may  be.  In  patients  from  the  East,  enlargement 
of  the  liver,  failing  other  and  more  obvious  explanation,  should 
suggest  the  possibility  of  Distomum  sinense  infection;  chronic  cough, 
rusty  sputa,  and  occasional  haemoptysis,  pulmonary  distomiasis.  In 
patients  from  Africa  or  Mauritius,  chronic  cystitis  and  haematuria  should 
suggest  a  microscopic  examination  of  the  urine  for  bilharzia  ova. 
The  discovery  of  the  ova  of  trematodes  in  the  stools  is,  of  course, 
diagnostic  of  the  presence  in  the  liver  or  alimentary  canal  of  their  special 
parental  forms. 

Prophylaxis. — The  boiling  of  drinking-water  and  the  avoidance  of 
uncooked  food,  including  vegetables,  are  obvious  precautions  indicated  by 
our  knowledge  of  the  life  history  of  these  parasites. 

Treatment. — Intestinal  flukes,  Distomum  crassum  and  Amphistomum 
hominis,  are  amenable  to  thymol,  which,  in  their  case,  may  be  administered, 
as  in  ankylostomiasis  (p.  549).  Flukes  occurring  in  the  bile  ducts  cannot 
be  dislodged  by  treatment. 


544  DISEASES  CAUSED  BY  ANIMAL  PARASITES. 

Pulmonary  distomiasis  is  also  incurable.  Severe  muscular  efforts,  as 
they  tend  to  cause  haemoptysis,  are  contra-indicated.  Symptoms  of 
cerebral  tumour  occurring  in  the  subject  of  pulmonary  distomiasis  should 
suggest  the  presence  of  a  distomum  tumour  in  the  brain,  and  the  feasibility 
of  excision. 

Bilharzia  disease  is  equally  incurable,  although  much  can  be  done  by 
judicious  living  to  avert  cystitis  and  severe  haemorrhage.  The  patient 
should  be  a  total  abstainer ;  he  should  avoid  a  rich  dietary  arid  give  up  all 
forms  of  exercise  entailing  succussion  or  necessitating  pressure  on  the 
perineum,  as  riding.  He  should  drink  freely  of  bland  diluents,  particu- 
larly during  intercurrent  attacks  of  cystitis,  and  keep  to  his  bed  at  such 
times.  Should  there  be  much  muco-pus  in  the  urine,  the  daily  washing 
out  of  the  bladder  with  warm  boric  acid  solution  is  indicated,  salol  being 
administered  internally  at  the  same  time.  Severe  and  persistent  chronic 
cystitis  may  be  much  relieved  by  cystotomy. 


NEMATODA. 

Zoology. — These  are  long,  slender,  bisexual  organisms.  The  cylin- 
drical body  tapers  towards  both  extremities,  at  one  of  which  is  placed 
the  mouth,  at  or  near  the  other  the  anus.  They  consist  of  a  musculo- 
cutaneous tube,  in  the  interior  of  which  lie,  (a)  the  straight  alimentary 
canal ;  (b)  in  the  case  of  the  male,  the  single  convoluted  testis  opening 
into  a  cloaca,  common  to  it  and  the  alimentary  canal  at  the  anus ;  (c)  in 
the  case  of  the  female,  two  much  convoluted  ovarian  tubes,  stuffed  with 
.ova  and  embryos  at  various  stages  of  development,  and  opening  into  a 
short,  vagina  which  usually  terminates  in  a  vulva  near  the  anterior  end 
of  the  worm.  Excretion  is  carried  on  by  two  vessels,  one  on  either 
side,  lying  in  a  vacant  space — the  lateral  lines — in  the  muscular  wall; 
anteriorly  these  vessels  unite  and  open  at  a  point,  the  vascular  pore, 
a  short  distance  behind  the  mouth.  The  male  worm,  which  invariably 
is  the  smaller,  has  a  sharply  curved  or  spiral  tail,  provided  with  one  or 
two  protrusible  chitinous  spicules  lodged  in  the  cloaca,  which  serve  to  fix 
the  female  in  coitu.  In  addition,  the  tail  of  the  male  is  also  generally 
furnished  with  two  rows  of  papillae,  placed  on  either  side  of  the  anus. 
Sometimes  there  are  membranous  appendages  of  a  more  or  less  complicated 
nature  at  the  head  or  tail. 

Certain  of  the  nematodes  are  oviparous  ;  others  are  viviparous,  or  ovo- 
viviparous.  The  embryos  are  minute  and  eel-like  in  shape  and  movement. 
In  many  instances,  prior  to  entering  the  definitive  host  they  pass  through 
an  elaborate  metamorphosis  in  the  body  of  another  animal,  the  inter- 
mediate host;  in  other  instances,  the  embryo  matures  outside  the  body, 
and  gives  rise  to  a  non-parasitic  generation,  whose  offspring,  on  being 
swallowed,  revert  once  more  to  the  parasitic  condition.  In  others,  the 
ova,  gaining  access  in  food  or  water  to  the  alimentary  canal  of  the  definitive 
host,  are  there  hatched  and  develop  into  mature  parasites. 

AscAKis  lumbeicoides,  or  round  worm  (Fig.  75),  common  in  most,  is 
very  common  in  many  countries,  particularly  in  the  tropics.  It  inhabits 
the  upper  part  of  the  small  intestine,  occasionally  wandering  into  the 
stomach  or  into  the  lower  part  of  the  bowel.  Both  sexes  are  plump, 
cylindrical,  grey  or   pinkish  in   colour,  shining,  transversely  and  finely 


NE  MA  TO  DA. 


545 


striated,  and  somewhat  rigid.  They  taper  gradually  towards  hoth  ends, 
particularly  towards  the  mouth,  the  three  lips  of  which  are  provided  each 
with  a  papilla. 

The  female  form,  much  the  larger,  measures  from  16  to  45  cms.  in 
length  by  6  mm.  in  diameter.  The  male,  readily  recognised  by  his  inferior 
dimensions  and  sharply  curved  tail,  measures  from  15  to  25  cms.  in  length 
by  4  mm.  in  diameter ;  two  short  spicules  protrude  usually  from  the 
cloaca,  on  either  side  of  which  is  a  row  of  some  seventy  minute  papUlse. 
In  both  sexes,  the  interior  vessels  can  readily  be  seen  shining  through  the 
musculo-cutaneous  body  wall. 


Fig.  75. — Ascaris  lumhricoides,  female. — Leuckart. 


The  ova  (Fig.  76)  (0-075  mm.  by  0'058  mm.)  vary  a  good  deal  in  contour, 
some  being  barrel-shaped,  others  oval  or  round.  They  possess  a  very  thick, 
rough,  multiple  outlined  brown  shell  and  granular  contents.  If  placed  in 
water  in  a  warm  place  and  exposed  to  the  light,  in  the  course  of  one  to 
six  months,  according  to  temperature,  an  embryo  is  developed.  Desicca- 
tion does  not  kill  the  embryo,  which  escapes  only  on  being  transferred  to 
the  stomach  of  man,  where  it  develops  in  the  course  of  a  month  into  a 
sexually  mature  parasite.  The  ova  are  present  in  the  fseces  in  prodigious 
numbers,  and  can  readily  be  recognised  by  the  microscope  (|  in.  objective). 

Symptoms. — These  parasites  are  most  prone  to 
occur  in  children ;  adults,  however,  are  by  no  means 
exempt.  In  warm  countries  few  escape  occasional  in- 
vasion of  this  sort.  In  some  instances  there  may  be 
only  one  or  two ;  in  other  instances  they  occur  in 
dozens,  or  even  in  hundreds.  Occasionally  they  crawl 
into  the  stomach,  and  at  times,  passing  up  the  oeso- 
phagus, escape  by  the  mouth  or  nostrils.  They  are 
sometimes  vomited,  especially  in  severe  fever;  some- 
times they  escape  spontaneously  in  the  faeces.  Al- 
though generally  so,  A.  lumhricoides  is  not  always  a 
harmless  parasite.  Cases  are  on  record  in  which  they 
produced  suffocation  by  creeping  into  the  rima  glottidis ;  they  have  been 
known  also  to  enter  the  bile  ducts,  producing  jaundice  and  even  hepatic 
abscess.  Sometimes  they  have  penetrated  the  gut  and  set  up  peritonitis. 
Such  events,  however,  are  rare  accidents.  As  a  rule,  the  ascaris  causes 
little  disturbance  ;  at  most,  vague  abdominal  discomfort.  In  children  they 
may  give  rise  to  peevishness,  foul  breath,  capricious  or  perverted  appetite, 
irregularity  of  the  bowels,  feverishness,  irritation  of  the  nose  and  anus,  and 
occasionally  convulsions. 

Treatment. — A  few  doses  of  santonin — -J-  to  5  grs.,  according  to 
age — is  a  certain  cure.  It  is  well  to  give  a  purge  a  few  hours  after  the 
santonin. 


■■cO^ 


Fib.  76.— Egg  from 
A.  lumhricoides 
fresh  from  the 
fteces. — Leuckart. 


A.  MYSTAX,  normally  parasitic  in  the  carnivora  (cat,  dog,  etc.),  sometimes 
vol.  i.— 35 


546 


DISEASES  CAUSED  BY  ANIMAL  PARASITES. 


occurs  in  man.  It  is  very  much  smaller  (male,  4  to  6  cms,  by  1  mm. ; 
female,  6  to  12  cms.  by  1*7)  than  A.  lumbricoides,  from  which  it  is  further 
distinguished  by  peculiarities  in  the  tail,  as  well  as  by  a  very  conspicuous 

cutaneous  wing  on  each  side  of  the  head. 
d  The  ova  (0-06S  by  O078  mm.)  are  covered  with 

a  sort  of  network  resembling  in  pattern  the 

mace  on  a  nutmeg. 


Oxyueis  vermicularis,  or  thread-worm 
(Fig.  77),  like  A.  lumbricoides,  is  a  cosmopoli- 
tan parasite,  occurring  most  frequently  in 
children.  Entering  the  alimentary  canal  as 
an  ovum,  it  is  hatched  out  in  the  stomach ; 
passing  thence  into  the  intestine,  it  rapidly 
attains  maturity.  After  copulation  the  male 
worm  usually  dies ;  the  female,  however, 
moves  on  to  the  caecum,  where  she  remains 
until  ovulation  is  complete.  She  then 
descends  to  the  rectum,  where,  in  some  in- 
stances, her  ova  (Fig.  78)  are  deposited  in, 
and  escape  with,  the  faeces. 

In  other  instances  the  parasite  spontane- 
ously emerges  from  the  anus  and  wanders 
about  over  the  skin  in  the  neighbourhood, 
giving  rise  to  much  irritation.  In  conse- 
quence of  the  scratching  so  provoked,  the 
worms  are  ruptured,  and  the  ova,  clinging  to 
the  fingers,  are,  during  the  picking  of  the 
nose  and  mouth,  so  frequent  a  concomitant 
of  thread-worms,  unconsciously  transferred 
to  the  patient's  mouth.  The  parasitism  is 
thus  kept  up  by  auto-infection.  It  may  also 
spread  by  contiguity  to  other  individuals,  as, 
for  example,  among  children  of  the  same 
family  or  school;  or  it  may  be  introduced 
through  contamination  of  the  food  or  water 
supply.  Unless  special  precautions  are  taken 
against  repeated  auto-infection,  a  constant 
succession  of  thread-worms  may  persist  in  the 

same  individual  for  years,  and  even  into  adult  life.     It  only  takes  fifteen 

days,  dating  from  the  introduction  of  the  ova  into  the  stomach,  for  the 

parasite  to  mature  and  begin  to  appear  in 

the  stools. 

The  female  worm  measures  from  9  mm. 

to  12  mm.  in  length,  by  0  4  mm.  in  breadth ; 

the  male  from  3  mm.  to  5  mm.  in  length, 

by  0-16  mm.  to  02  mm.  in  breadth.    In  both 

sexes,  under  the   microscope,  the  head   is 

seen  to  be  furnished  with  a  characteristic 

cuticular  appendage,  shaped  like  the  mouth- 
piece  of   a  Turkish  tobacco-pipe.     In   the 

female  the  anus  is  placed  at  the  base  of 

the    sharp-pointed    straght    tail.      In    the 


Fig.  77. — Oxyuris  vermicularis.  (a) 
Male  (nat.  size) ;  (b)  male  (magni- 
fied) ;  (c)  female  (nat.  size) ;  (d) 
female  (magnified). — Leuckart. 


Fig.  78.— Eggs  of  0. 
[a,  b)  freshly  laid 


vermicularis. 
(c)  with  de- 


veloped embryo. — Leuckart. 


NEMATODA.  547 

male  the  anus  is  terminal,  and  the  tail,  which  is  provided  with  a 
single  spicule  and  six  pairs  of  papillae,  is  truncated  and  generally 
coiled  up. 

The  anal  irritation  set  up  by  these  worms  is  often  exceedingly  trouble- 
some, and  from  the  broken  sleep  and  constant  worry  it  entails,  may 
seriously  impair  the  health.  It  is  always  most  troublesome  when  the 
child  is  warm  in  bed,  the  warmth  of  surface  seemingly  inducing  the  worms 
to  wander  out  by  the  anus.  If  the  stools  of  such  a  patient  be  inspected, 
numerous  slowly  moving  parasites,  looking  like  short  lengths  of  white 
thread,  can  be  detected ;  these  are  the  female  oxyurides.  The  male  are 
not  only  few  in  number,  but,  owing  to  their  small  size,  are  easily 
overlooked. 

The  ovum  (Fig.  78)  (0-05  mm.  by  0-016  mm.  to  0-024  mm.)  generally 
contains  a  differentiated  embryo.  It  is  further  distinguished  by  its  treble 
outlined  shell ;  this  is  distinctly  flattened  on  one  side,  being  defective  as 
regards  the  middle  layer  on  the  other  or  more  convex  side. 

Treatment. — An  important  step  in  treatment  is  the  recognition  of 
the  way  by  which  an  infection  is  kept  up.  The  attendants  of  children 
should  be  thoroughly  informed  on  this  point,  and  instructed  to  make 
provision,  either  by  means  of  drawers  or  by  tying  up  the  end  of  the  night- 
dress, against  the  child  reinfecting  itself.  An  infected  child  should  not  be 
allowed  to  sleep  with  other  children.  The  nocturnal  anal  irritation  is  best 
prevented  by  smearing  some  weak  form  of  mercurial  ointment,  or  carbolic 
oil,  or  similar  drug  about  the  anus ;  these  kill  the  emerging  worms.  Those 
parasites  still  in  the  csecum  cannot  very  well  be  dislodged ;  but  those  that 
liave  descended  to  the  rectum  are  easily  got  rid  of  by  enemata  administered 
every  night,  or,  later,  every  third  night,  of  salt  water,  infusion  of  quassia, 
of  water  containing  a  few  drops  of  tinct.  ferri  perchloridi,  lime  water, 
vinegar  and  water,  etc.  Occasional  aperients  should  be  given  at  the 
same  time. 

Eustrongylus  gigas  (or  giant  strongyle)  has  been  found  six  or  seven 
times  in  man.  It  is  especially  a  parasite  of  the  ichthyophagous  carnivora, 
in  whom  it  occurs  in  many  countries.  Its  habitat  is  the  kidney,  which  it 
destroys,  converting  the  organ  into  a  bag  of  pus,  and  giving  rise  to  renal 
pain,  purulent  urine,  and  hematuria.  The  foveolated  ova  (0-065  mm.  by 
0-043  mm.)  appear  in  the  urine,  and  are  diagnostic  of  the  condition.  These 
formidable  nematodes  attain  enormous  dimensions ;  the  male,  recognised 
"by  the  terminal  copulatory  bursa  and  solitary  spicule,  measures  from 
14  to  25  cms.  in  length,  by  4  to  5  mm.  in  diameter ;  the  female,  25  cms.  to 
1  metre  in  length,  by  4-5  to  12  mm.  in  diameter.  This  parasite,  if  its 
presence  has  been  recognised,  could  be  easily  removed  by  surgical 
means. 

Ankylostemum  duodenale  (Dochmius  chiodenalis,  or  the  tunnel-worm). 
(Fig.  79).  On  account  of  the  grave  cachexia  to  which  it  frequently  gives 
rise,  and  on  account  of  its  frequency,  this  is  one  of  the  most  important 
animal  parasites  affecting  man.  It  is  extremely  prevalent  in  many  warm 
countries ;  in  Europe,  though  very  much  rarer,  it  has  been  the  cause  of  many 
epidemics  of  the  characteristic  and  often  fatal  ansemia  with  which  it  is 
associated.  It  has  been  found  as  far  north  as  the  51st  parallel; 
probably  it  has  a  corresponding  southern  limit.  In  Egypt  it  is  almost 
general.     In  many  parts  of  India  it  is  present  in  75  per  cent,  of  the  adult 


54§ 


DISEASES  CA  USED  BY  ANIMAL  PARASITES. 


population.     In  Africa,  in  the  West  Indies,  in  Brazil,  and  in  many  other 
tropical  countries,  it  is  probably  equally  prevalent. 

The  ankylostomum  inhabits  the  upper  part  of  the  jejunum,  and,  to 
some  extent,  the  duodenum  and  ileum,  to  the  mucous  membrane  of  which 
it  attaches  itself  by  a  powerful  and  remarkable  buccal  armature.  It 
derives  its  nourishment  from  the  blood  it  freely 
ingests.  From  time  to  time  it  shifts  its  hold,  the 
abandoned  bite  oozing  a  little  blood,  and  thereby 
leading  to  further  depletion  of  the  patient. 

The  male  worm  (Fig.  80)  measures  from  6  to 

11  mm.  in  length,  by  O'-l  to  05  mm.  in  diameter ; 

the  female,  which  is  three  times  as  numerous  as  the 

male,  measures  7  to  1 5  mm.  by  1  mm.     Both  sexes 

are  white  or  reddish  brown  in  colour,  and  cylindrical 

in  shape,  the  posterior  end  being  the  broader.     The 

tapering  neck  ends  in  a  cup-shaped  expansion,  or 

mouth  capsule,  the  lips  of  which  are  provided  with  four  hooks  and  two 

teeth.     The  caudal  end  of  the  female  terminates  in  a  short  spine,  at  the 

base  of  which  is  the  anus ;  the  vagina  opens  considerably  in  advance  of 


Fig.  79. — Ankylostomum 
duodenale,  male  and 
female.  — Blanchard. 


Fig.  80. — Male  ankylostomum  duodenale. 


this.  The  caudal  end  of  the  male  is  expanded  into  a  trilobed,  umbrella- 
like bursa ;  at  the  bottom  of  this  is  the  cloaca,  from  which  two  very  long 
and  delicate  spicules  emerge.  The  female  emits  a  vast  number  of  ova 
(Fig.  81)  (0-06  by  0-04  mm.),  which  appear  in  the  fasces,  and  can  be 
recognised  readily  by  their  regular  oval  form,  delicate,  single  outlined, 
transparent  shell  enclosing  two  to  eight  greyish  yolk 
spheres.  Very  active  rhabditiform  embryos  are  de- 
veloped soon  after  the  ova-charged  faeces  escape  from 
the  host.  After  two  moultings  the  embryo  passes 
into  a  larval  condition,  and  if  now  transferred  in 
dirty  water,  or  in  earth,  or  by  dirt-soiled  hands  or 
food  to  the  human  stomach,  rapidly  develops  into  the 
mature  parasite.  Some  authorities  assert  that  the 
ankylostomum  can,  for  one  or  two  generations,  reproduce  itself  hetero- 
genetically  wrhilst  outside  the  human  body.  It  is  difficult  to  determine 
how  long  the  individual  parasites  live  in  the  host;  certainly  it  is  for 
many  months,  possibly  for  several  years. 

If  these  parasites  are  present  in  the  intestine  in  large  numbers,  or  if 


Fig.  81. 


— A.  duodenale. 
Sonsino. 


NEMATODA.  549 

the  subject  of  the  infection  is  poorly  nourished,  or  of  feeble  constitution, 
the  persistent  drain  of  blood  and  the  dyspeptic  conditions  entailed  by 
the  injuries  to  the  mucous  membrane  and  possibly  the  absorption  of 
some  poisonous  substance  eliminated  by  the  worm,  gradually  or  more 
rapidly  lead  to  the  production  of  a  cachexia  which  persists  and  increases 
so  long  as  the  stock  of  parasites  is  kept  up.  Ultimately  the  infection  may 
prove  fatal  from  pure  antenna,  or,  it  may  be,  by  predisposing  to  other 
disease.  In  many,  without  causing  actual  disease,  it  nevertheless  leads  to 
a  condition  of  debility  unfitting  for  active  labour.  Ankylostomiasis  is  now 
the  recognised  cause  of  much  of  the  anaemia  which  is  so  common  in 
the  natives  of  tropical  countries,  and  as  being  at  the  root  of  such 
affections  as  Egyptian  chlorosis,  the  cachexia  aqueuse  of  the  West  Indian 
negroes,  and  of  other  similar  conditions. 

Symptoms. — The  subjects  of  extensive  ankylostomiasis  frequently 
suffer  from  forms  of  dyspepsia  in  which  epigastric  tenderness,  borborygmus, 
capricious,  inordinate,  or  perverted  appetite  are  apt  to  be  prominent 
symptoms.  Many  exhibit  a  craving  for  earth,  or  lime,  or  similar  sub- 
stances— pica,  geophagy.  Gradually  all  the  symptoms  of  a  profound 
anaemia  are  evolved,  including  languor,  pallor,  breathlessness,  vertigo, 
tinnitus,  syncope.  Though  the  surfaces  are  pale,  the  body  is  plump  and, 
towards  the  latter  stages,  puffy  from  oedema.  If  the  stools  in  such  a  case 
be  examined,  there  is  usually  no  difficulty  in  finding  with  the  microscope 
numerous  ova  (Fig.  81)  of  the  parasite.  In  all  cases  of  tropical  anaemia, 
for  which  the  cause  is  not  obvious,  such  an  examination  should  be  made. 
It  sometimes  happens  in  long-standing  cases  of  ankylostomiasis,  or  of  cases 
which,  presumably,  at  the  outset  were  cases  of  ankylostomiasis,  that  the 
parasites,  the  original  cause  of  the  anaemia,  have  died  out.  In  such  cases 
ova  will,  of  course,  not  be  found ;  it  is  to  be  presumed  that  the  lesions 
in  the  alimentary  canal,  the  fatty  degeneration  of  the  heart  muscle,  and 
other  organic  changes,  the  result  of  the  prolonged  anaemia,  keep  up  the 
cachexia  and  prevent  recovery. 

Treatment. — The  patient  should  be  placed  for  a  day  or  two  on  fluid 
diet,  and  a  mild  saline  administered.  Next  morning,  fasting,  three  or  four 
doses  of  from  15  to  30  grs.  each  of  thymol,  in  cachets  or  emulsion, 
are  administered  at  intervals  of  one  to  two  1  hours,  the  last  dose,  if  the 
bowels  have  not  acted  freely,  being  accompanied  by  a  purge.  Many 
ankylostomes  will  be  expelled,  and  can  readily  be  recovered  from  the  stools 
by  washing.  If,  after  ten  days  or  a  fortnight,  ova  are  still  present  in  the 
stools,  the  thymol  course  must  be  repeated.  As  a  rule,  this  second  course 
is  not  required,  the  patient,  under  judicious  feeding,  rapidly  regaining 
strength  and  colour. 

Certain  precautions  are  to  be  observed  in  the  administration  of  this 
valuable  drug.  Thymol  often  produces  a  form  of  intoxication  ;  therefore, 
while  under  its  influence,  the  patient  should  be  kept  lying  down.  Though 
feebly  soluble  by  the  intestinal  juices,  thymol  is  readily  dissolved  by 
alcoholic  fluids,  by  ether,  turpentine,  oils,  glycerin,  chloroform,  and 
alkalies  ;  therefore  these  things  must  be  carefully  eschewed  until  the  drug 
has  been  voided.  Neglect  of  this  obvious  precaution  has  led  to  fatal 
poisoning.  In  cases  in  which  the  patient  is  very  low,  it  is  well  to  post- 
pone the  use  of  the  drug  until,  by  careful  feeding  and  by  rest,  strength 
has  been  somewhat  restored. 

Filix  mas,  formerly  much  used  as  a  vermifuge  in  ankylostomiasis, 
is  still  occasionally  employed  in  doses  similar  to  those  for  tape-worm. 


55o  DISEASES  CAUSED  BY  ANIMAL  PARASITES. 

It  is  not  so  efficient  as  thymol,  and,  like  that  drug,  has  also  the  draw- 
back of  occasionally  producing  toxic  symptoms.  It  has  the  additional 
disadvantage  of  costliness  and  liability  to  adulteration  or  to  inertness. 

Prevention. — From  the  fact  that  the  ankylostomum  enters  the 
body  in  dirty  water,  on  dirty  fingers,  dishes  and  food,  in  the  endemic  area 
great  care  should  be  exercised  to  keep  the  water  supply  uncontaminated 
by  faecal  matter.  Suspicious  water  should  be  boiled.  Coolies  and  others 
must  not  be  allowed  to  eat  with  earth-soiled  hands,  or  out  of  dirty  dishes. 
Proper  latrines  should  be  provided,  and  all  faecal  matter  destroyed 
by  fire  or  buried.  Soil  contaminated  with  fasces  should  be  dug  over, 
or  otherwise  dealt  with  so  as  to  secure  destruction  of  the  ova  or  larval 
ankylostoma. 

Trichocephalus  dispar,  or  whip-worm  (Fig.  82),  so  called  from  its 
peculiar  shape,  inhabits  the  caecum  and,  occasionally,  other  regions  of  the 
alimentary  canal,  to  the  surface  of  which  it  sometimes  attaches  itself  by 
transfixing  the  mucous  membrane  with  its  long  capillary  neck ;  usually  it 
is  found  lying  loose  on  the  surface  of  the  mucosa. 

The  sexes  resemble  each  other  as  regards  length  (35  to  45  mm.), 
but  the  male  can  be  distinguished  by  his  coiled  up  caudal  end  from  the 


Fig.  82. — Trichocepjialus  dispar,  in  situ. —  Fig.  83. — T.  dispar. — 

Leuckart.  Sonsiuo. 

extremity  of  which  a  single  spicule,  enclosed  in  a  trumpet-shaped  sheath, 
can  be  seen,  with  the  microscope,  to  be  protruding.  In  the  female  the 
tail  tapers  gradually  to  a  sharp  point,  the  anus  being  subterminal;  the 
vagina  opens  at  the  root  of  the  long  hair-like  neck.  In  both  sexes  the 
posterior  part  of  the  worm  is  much  the  thicker,  and  contains  the  sexual 
organs. 

The  ova  (Fig.  83)  (0-05  by  O025  mm.)  are  oval,  smooth,  thick-shelled, 
dark  brown,  and  without  differentiated  embryo.  They  are  readily  recog- 
nised by  their  somewhat  pointed  ends,  which  exhibit  a  clear,  plug-like 
protuberance  filling  up  a  gap  in  the  shell.  The  ova  mature  in  water, 
but  only  after  a  very  long  time — twelve  to  eighteen  months.  When  the 
embryo  has  completed  development,  on  transference  to  the  human 
stomach  the  shell  of  the  egg  is  dissolved  off  and  development  proceeds.  In 
the  course  of  from  four  to  five  weeks  the  parasite  becomes  sexually 
mature,  her  ova  escaping  in  the  faeces,  in  which  they  can  readily  be 
recognised  with  a  low  power  of  the  microscope. 

T.  dispar  is  cosmopolitan.  In  many  European  countries  it  is  present 
in  half  the  population.  In  tropical  countries  it  is  almost  universal.  .  The 
prevalence  of  the  parasite  depends  in  great  measure  on  the  character  of 
the  water  supply. 

T.  dispar,  apparently,  gives  rise  to  no  symptoms,  and  is  of  no  patho- 


NEMA  TO  DA. 


551 


logical  importance — a  fortunate  circumstance,  seeing  that  it  is  but  slightly 
amenable  to  anthelmintics. 


Trichina  spiralis. — This  nematode,  which  in  natural  condition  seems 
to  be  more  especially  a  parasite  of  the  rat,  is  acquired  by  man  through 
eating  raw  or  imperfectly  cooked  pork,  pork  sausages,  lard,  or  other 
preparation  of  swine's  liesh.  The  dangerous 
disease  it  gives  rise  to  is  called  trichiniasis 
or  trichinosis. 

If  the  muscles  of  a  pig  affected  with 
trichina  be  closely  scrutinised  with  a  lens, 
they  are  seen  to  be  besprinkled  with  numer- 
ous white  specks.  If  a  portion  of  muscle, 
after  teasing  out  in  normal  salt  solution  and 
compression  under  a  cover-glass,  be  placed 
under  the  microscope,  these  white  specks  are 
found  to  be  minute  (0-4  by  025  mm.)  lemon- 
shaped  cysts  (Fig.  8-45),  lying  lengthways 
between  the  fibres,  each  containing  a  coiled- 
up  cylindrical  worm,  occasionally  two  or 
more  worms,  which,  on  the  slide  being  slightly 
warmed,  exhibit  slow  movement.  The  worms 
measure  about  1  mm.  in  length.  An  ali- 
mentary canal  runs  from  the  narrower  oral 
end  to  the  thicker  abruptly  truncated  anal 
end;  rudimentary  organs  of  generation  can 
also  be  distinguished. 

If  a  portion  of  the  affected  flesh  be  given 
to  a  dog,  or  other  mammal,  the  cysts  are 
digested  off  by  the  gastric  juices.  The  worms 
survive  and  pass  into  the  duodenum.  In  the 
course  of  one  or  two  days  they  attain  sexual 
maturity,  measuring  at  this  time  about  T5 
mm.,  the  female  (c)  being  somewhat 
the  larger.  The  male  is  provided  with  two 
caudal  appendages,  by  which  the  female  is 
secured  during  coitus.  This  function  effected, 
he  dies.  The  female,  however,  continues  to 
grow,  ultimately  attaining  a  length  of  from 
3  to  4  mm.  On  the  sixth  or  seventh  day 
after  ingestion  the  first  young  are  born. 
They  are  minute,  lancet-shaped  organisms 
(1  by  0-006  mm.),  rounded  anteriorly, 
and  tapering  towards  the  tail  {a).  The 
female  daring  some  six  weeks  emits  a  continuous  stream  of  young, 
which  penetrate  the  walls  of  the  alimentary  canal,  and,  crossing  the 
peritoneal  cavity,  travel  along  the  connective  tissue  spaces.  Finally, 
arriving  at  the  muscles,  they  encyst  themselves,  forming  a  capsule  out 
of  the  hyperplasia  of  connective  tissue  cells  provoked  by  the  irrita- 
tion of  their  presence.  Encystment  is  complete  in  about  eighteen  days 
from  the  date  of  infection.  By  this  time  the  young  trichina  has  increased 
in  size,  and  so  far  advanced  in  development,  that,  on  being  transferred 
to   the   stomach  of  a  suitable  mammal,  it  is  capable  of   proceeding   to 


Fig.  84. — Trichina  spiralis. 
Embryo  ;  (b)  intermediate  form  ; 
(c)  sexual  form.  (Ummpregnated 
female. ) — Leuckart. 


552  DISEASES  CAUSED  BY  ANIMAL  PARASITES. 

sexual  maturity.  The  encysted  trichina  retains  its  capacity  for  develop- 
ment for  many  years — five  to  twenty,  it  is  said ;  ultimately,  however,  it 
dies,  and  the  capsule  becomes  cretified. 

The  pillars  of  the  diaphragm,  and  the  intercostal  muscles,  especi- 
ally the  diaphragm,  are  the  muscles  most  affected.  But  the  parasites 
are  to  be  found  in  every  muscle  of  the  body  (with  the  exception 
of  the  heart,  which  is  rarely  invaded),  and  more  especially  towards  their 
tendinous  ends.  They  are  not  confined,  however,  to  the  muscles,  but 
encyst  themselves  in  the  panniculus  adiposus  also,  and  even  in  the  walls 
of  the  alimentary  canal ;  lard  and  sausage  skins,  therefore,  may  prove 
infective  and  dangerous. 

The  encysted  trichinae  possess  great  powers  of  resistance.  Decom- 
position, chemical  substances  such  as  pickling  fluid,  freezing,  and  tempera- 
tures up  to  80°  C.  fail  to  kill  them.  Unless  a  ham  or  joint  of  pork  be 
thoroughly  cooked,  any  trichinae  that  may  be  in  the  centre  of  the  piece 
will  not  be  killed.  A  safe  rule  as  regards  prevention  of  trichiniasis 
is  to  cook  such  viands  thirty-five  minutes  for  every  kilogramme  of 
weight. 

Wherever  rats  and  pigs  are  found, — that  is,  practically  everywhere, 
— trichiniasis  may  occur.  Owing  to  the  thorough  cooking  to  which  pre- 
parations of  pork  are  subjected  in  Britain,  the  disease  is  rare  in  this 
country ;  but  in  Germany,  where  pork  sausages  and  ham  are  frequently 
consumed  in  a  half-cooked  or  raw  state,  until  stringent  inspection  of  the 
carcases  of  all  swine  killed  for  the  market  was  instituted,  trichiniasis  was 
not  uncommon. 

Symptoms. — Minor  degrees  of  trichiniasis  are  probably  often  over- 
looked; but  the  clinical  features  of  the  severer  degrees  of  infection, 
especially  if  the  disease  occur  as  a  circumscribed  and  sudden  epidemic,  are 
so  distinctive,  that  it  should  be  readily  recognised.  The  severity  of  the 
individual  cases  varies  very  much  according  to  circumstances.  The 
larger  the  amount  of  infected  food  consumed,  and  the  greater  the 
number  of  larval  trichinae  the  meat  contains,  the  more  severe  will  be 
the  disease.  On  the  whole,  trichiniasis  is  less  dangerous  to  children  than 
to  adults.  The  cases  range  in  severity  from  a  mild  gastro-intestinal 
derangement,  followed  by  rheumatic-like  muscular  pains,  to  a  choleraic- 
like  disease  followed  by  intense  general  myositis,  a  typhoid  condition,  and 
death.  In  a  case  of  moderate  severity,  it  is  possible  to  recognise  three 
stages :  first,  one  of  gastro-intestinal  irritation ;  second,  one  of  myositis ; 
and  third,  one  of  convalescence. 

Within  a  few  hours  of  swallowing  trichiniased  flesh,  symptoms  of  acute 
irritation  of  the  upper  part  of  the  alimentary  canal  set  in.  There  is 
purging  and  vomiting,  foul  tongue,  anorexia,  colic,  and  prostration.  These 
symptoms  correspond  with  the  growth  and  sexual  activity  of  the  parent 
trichinae,  and  the  subsequent  penetration  of  the  intestinal  canal  by  their 
migrating  offspring.  Such  symptoms  may  continue  for  a  week  or  ten  clays, 
or  even  longer.  Then  follow  symptoms  indicative  of  the  invasion  of 
the  muscles  by  the  parasites.  There  is  pain,  tenderness,  and  hard 
swelling  of  the  muscles,  together  with  fever,  the  thermometer  rising  to 
103°  or  even  to  106°  F.  Movement  becomes  intensely  painful;  and, 
owing  to  implication  of  the  diaphragm  and  intercostal  muscles,  respira- 
tion may  be  seriously  interfered  with.  Similarly  mastication,  deglu- 
tition, phonation,  and  ocular  movement  may  all  become  impaired  or 
impossible   from   the  same   cause.     The  patient   lies  in   bed   with  limbs 


NEMATODA. 


553 


semiflexed  and  motionless.  About  the  eighth  day  there  is  marked 
puftiness  of  the  face,  especially  about  the  eyelids ;  occasionally  there 
is  chemosis  in  the  latter  situation.  This  puftiness  subsides  in  a  few 
days;  but  towards  the  fourth  or  fifth  week,  general  oedema,  sometimes 
very  pronounced  and  resembling  that  of  acute  nephritis,  sets  in.  This 
oedema  may  come  and  go.  At  the  same  time  there  is  profuse  sweating, 
and  sudamina  and  various  skin  eruptions,  as  pimples  and  boils,  may  appear. 
Wasting  and  a  typhoid  condition  are  now  pronounced,  and  may  be  accom- 
panied by  delirium  or  stupor.  In  adults  insomnia  is  apt  to  be  a  marked 
feature,  doubtless  in  great  measure  caused  by  the  pain  in  the  muscles. 
Children,  however,  are  always  somnolent.  Bronchitis  or  pneumonia  may 
also  supervene. 

If  the  patient  survive,  improvement  may  be  looked  for  about  the 
sixth  week ;  that  is,  when  the  trichinae  have  completed  encystment,  and 
the  myositis  begins  to  subside.  In  mild  cases  improvement  may  set  in 
earlier ;  on  the  other  hand,  it  may  be  delayed  for  two  or  three  months. 
Death  may  occur  in  the  early  stages  from  the  violence  of  the  initial 
choleraic  symptoms.  Usually  it  does  not  occur  till  the  height  of 
the  myositis,  when  it  may  be  brought  about  by  asphyxia  from  implica- 
tion of  the  respiratory  muscles,  or  by  some  intercurrent  complication 
such  as  pneumonia.  A  tedious  marasmus  may  prove  fatal  at  a  later 
period. 


Fig.  85. — Guinea-worm.     (Reduced.) — Leuckart. 


The  mortality  in  trichiniasis  varies  in  different  epidemics,  and  within 
wide  limits — from  1  or  2  to  30  per  cent. 

Diagnosis. — The  diseases  with  which  trichiniasis  is  most  apt  to  be 
confounded  are  cholera,  acute  rheumatism,  typhoid  fever,  and  beriberi. 
Whenever  there  is  a  doubt,  the  stools  should  be  searched  for  adult 
trichinae ;  or,  if  necessary,  a  small  piece  of  muscle  excised  and  examined 
with  the  microscope.  Eecent  observations  in  America  have  established 
the  striking  fact,  that  the  acute  stage  of  trichiniasis  is  accompanied  by  a 
remarkable  increase  of  eosinophile  leucocytes  in  the  blood,  a  circumstance 
which  has  been  successfully  applied  in  diagnosis. 

Treatment.— If  the  case  is  seen  early,  with  the  view  of  getting  rid 
of  any  trichinous  food  that  may  still  remain  in  the  stomach,  quickly 
acting  emetics  are  indicated.  Free  purging,  so  long  as  it  is  to  be  presumed 
that  there  are  parent  trichinae  in  the  alimentary  canal,  should  be  encour- 
aged, best  by  large  doses  of  calomel.  Thymol,  given  as  in  ankylostomiasis, 
would  probably  be  of  great  service  at  this  stage.  The  subsequent  stage  of 
myositis,  and  the  concomitant  typhoid  condition,  are  to  be  treated  on 
general  principles. 

Filakia  medinensis  (Fig.  85)  {Dracunculus  medinensis,  or  guinea- worm), 
unknown  as  an  indigenous  parasite  in  Europe,  is  common  in  many  parts  of 
Africa,  especially  on  the  West  Coast,  in  India,  Persia,  Turkestan,  and 
Arabia.     It  is  found  in  one  or  two  places  in  Brazil,  but  nowhere  else  in 


554 


DISEASES  CAUSED  BY  ANIMAL  PARASITES. 


America.  It  special  habitat  is  the  connective  tissue  of  man,  and  occasion- 
ally of  some  of  the  larger  mammalia. 

The  guinea-worm  attains  a  length  of  from  1  to  6  ft.,  and  a  diameter  of 
TXo  in.  It  is  white,  smooth,  polished,  extensile,  cylindrical,  abruptly  trun- 
cated at  the  head,  and  terminates  in  a  short,  stout  hook  at  the  tail.  A 
slender  alimentary  tube  runs  along  the  entire  length  of  the  worm,  from  the 
punctiform  mouth  to  close  to  the  tail,  where  it  merges  into  the  body  wall ; 
there  is  no  anus.  The  greater  part  of  the  cylinder  formed  by  the  musculo- 
cutaneous body  wall  is  occupied  by  the  relatively  huge  uterus,  which, 
extending  from  head  to  tail,  is  packed  with  myriads  of  coiled  up  embryos 
(Fig.  8Q).  In  the  mature  worm,  whatever  may  be  the  case  in  early  life, 
there  is  no  vagina.     The  male  parasite  is  unknown. 

When  the  young  guinea-worm  enters  the  human  body,  presumably  in 


Fig.  86. — Embryos  of  guinea-worm. 

drinking  water,  she  is  probably  of  microscopic  dimensions.  Analogy 
indicates  the  conclusion  that,  after  penetrating  the  walls  of  the  stomach  or 
intestine,  the  young  worm  works  its  way  into  the  connective  tissue,  to 
remain  there  in  a  more  or  less  passive  condition  until  the  uterine  contents 
have  attained  a  certain  stage  of  development.  When  or  where  impregna- 
tion is  effected  is  not  known.  In  the  course  of  about  one  year  the  now 
matured  and  gravid  worm  proceeds  to  migrate  to  the  position  most  favour- 
able for  affording  her  young  access  to  the  medium — fresh  water — in  which 
the  first  stage  of  their  lives  is  passed.  Occasionally,  though  rarely,  she 
may  appear  about  the  scrotum,  abdomen,  arms,  or  even  the  scalp ;  in  95 
per  cent,  of  cases  she  descends  to  the  legs  or  feet.  She  then  drills  a  small 
hole  in  the  derma,  the  epidermis  becoming  raised  up  as  a  bleb  over  the 
site  of  the  hole.  When,  after  a  day  or  two,  this  bleb  ruptures,  a  super- 
ficial ulceration  or  excoriation  —  half  an  inch  to  an  inch  in  diameter 
— is  disclosed ;    in  the  centre  of  this  sore  the  hole  referred  to  can  be 


.NEMATODA.  555 

detected.  In  some  instances,  on  the  rupture  of  the  bulla,  the  head  of 
the  worm  is  seen  protruding  from  the  central  hole ;  usually,  however, 
this  is  not  so,  the  head  being  retracted  and  out  of  sight.  If  now  the 
foot  of  the  patient  be  placed  in  cold  water,  or  if  a  little  cold  water 
be  allowed  to  trickle  on  to  the  skin  in  the  vicinity  of  the  sore,  in  the 
course  of  a  few  seconds  a  droplet  of  whitish  fluid  is  seen  to  well  out  from 
the  central  hole ;  in  other  instances,  a  slender  tube  is  slowly  protruded, 
and,  under  the  influence  of  a  vis  a  tergo,  becoming  tense,  presently  ruptures, 
a  similar  whitish  fluid  escaping.  This  tube  is  undoubtedly  the  uterus, 
prolapsed  through  the  mouth  in  consequence  of  the  contraction  of  the 
musculo-cutaneous  structures  of  the  worm,  in  response  to  the  stimulus  of 
the  cold  water.  If  a  little  of  the  whitish  fluid  is  placed  under  the  micro- 
scope, it  will  be  found  to  contain  enormous  numbers  of  coiled-up  passive 
embryos,  which,  on  the  instillation  of  a  little  water  under  the  cover- 
glass,  immediately  commence  to  swim  about  with  great  activity  (Fig. 
86).  These  embryos  measure  -^  of  an  in.  in  length,  by  ToVo-  of  an  in.  in 
breadth.  Anteriorly,  they  are  rounded  off;  posteriorly,  they  taper  to  a 
long,  slender  swimming  tail,  at  the  root  of  which  two  peculiar  gland- 
like organs  are  apparent.  An  alimentary  canal  is  distinctly  visible,  but  no 
organs  of  generation  can  be  made  out.  The  cuticle  of  the  embryo  is  some- 
what coarsely,  transversely  striated.  The  body  is  not  cylindrical,  but 
compressed  laterally,  so  that,  as  the  animal  swims  with  its  longer  trans- 
verse diameter  in  a  vertical  position,  the  embryo  looks  much  narrower 
when  in  motion  than  when  at  rest  and  lying  on  its  flat  surface.  These 
embryos  will  live  for  several  weeks,  especially  if  placed  in  muddy  water. 

If  a  number  of  embryos  are  placed  in  water  in  a  watch-glass  along 
with  a  fresh-water  cyclops,  they  attack  the  cyclops,  and, penetrating  the  joints 
of  the  latter,  enter  its  body  cavity  and  ultimately  undergo  a  remarkable 
metamorphosis.  They  cast  their  skins  two  or  three  times,  get  rid  of  their 
swimming  tails,  acquire  a  more  complete  alimentary  canal,  rudimentary 
organs  of  generation,  and  a  peculiar  tripod-like  caudal  appendage.  It  is 
presumed  that,  after  this  metamorphosis  is  completed,  the  young  guinea- 
worm  is  ready  for  transference  to  the  human  stomach. 

When  the  parent  guinea-worm,  after  penetrating  the  skin,  in  the  course 
of  a  fortnight  or  thereby  has  emptied  her  uterus,  she  exhibits  a  tendency 
to  quit  the  body  of  her  human  host.  At  this  stage  she  can  be  withdrawn 
with  comparative  ease;  prior  to  this  she  resists  attempts  at  extraction,  and 
frequently  ruptures  under  the  strain  of  misdirected  efforts  made  for  her 
removal.  As  a  rule,  only  one  guinea-worm  presents  at  a  time,  but  cases 
of  multiple  infection  are  common ;  two  or  three  are  by  no  means  unusual, 
and  sometimes  dozens  may  be  present. 

Just  before  the  guinea-worm  appears,  the  patient  may  be  attacked  with 
fever  and  urticaria.  If  properly  managed,  the  presence  of  this  parasite 
may  cause  but  little  trouble ;  but  if,  in  consequence  of  injudicious  attempts 
at  extraction,  the  worm  should  be  ruptured,  and  occasionally  even  without 
such  interference,  violent  inflammation  of  the  limb  ensues,  leading  to 
abscess,  sloughing  of  the  tissues,  and,  as  a  consequence  of  this,  not 
infrequently,  contractions  and  deformities.  Death  may  result  from  septic 
trouble. 

Treatment. — It  is  evident  that  in  guinea-worm  districts  the  drinking 
water  must  be  carefully  attended  to,  and  boiled  or  filtered  if  from  a 
suspicious  source.  The  subjects  of  guinea-worm  must  not  be  allowed  to 
bathe  their  sores  in  the  vicinity  of  the  water  supply. 


556  DISEASES  CAUSED  BY  ANIMAL  PARASITES. 

Formerly  it  was  the  practice  to  attempt  to  wind  out  the  worm  by 
attaching  the  protruding  head,  so  soon  as  it  could  be  laid  hold  of,  to  a 
piece  of  wood,  and  making  a  few  turns  of  this  daily.  This  practice  is 
dangerous,  and  should  not  be  attempted  until  the  uterus  of  the  parasite 
has  emptied  itself ;  then,  but  not  before,  the  natural  tendency  of  the 
■worm  to  come  out  may  be  encouraged  by  the  winding  -  out  method. 
Eecently  Emily  has  introduced  what  he  and  others  maintain  is  a  much 
more  expeditious  and  safer  way  of  dealing  with  guinea-worm.  If  the 
worm  is  presenting,  he  injects  her,  by  means  of  a  hypodermic  syringe 
introduced  into  her  mouth  or  body,  with  perchloride  of  mercury  solution, 
1  in  1000.  This  kills  the  worm,  and  renders  her  track  aseptic;  in  a 
few  hours,  if  so  treated,  she  can  easily  be  removed  by  judicious  winding- 
out.  If  she  has  not  penetrated  the  skin,  although  her  coils  can  be 
detected  in  the  subcutaneous  tissue,  the  perchloride  solution  is  injected 
at  several  points  as  near  the  body  of  the  worm  as  possible.  This  also  kills 
her.  She  may  then,  after  a  few  hours,  be  cut  down  on  and  removed  by 
careful  traction,  or  she  may  be  left  alone  ;  in  the  latter  event  the  dead  body 
is  absorbed  like  a  piece  of  aseptic  catgut. 

Occasionally  the  guinea-worm  dies  before  she  has  pierced  the  skin. 
Abscess  may  ensue ;  or  the  parasite  may  be  absorbed ;  or  it  may  become 
cretified,  and  for  years  remain  as  a  hard  innocuous  con- 
^— 9  voluted  cord,  easily  felt  beneath  the  skin. 

Filaria  LOA  (Fig.  87). — In  many  parts  of  the  West 
Fig.  87.— Filaria  Coast  of   Africa,  the  natives,  and  occasionally  the  Euro- 
— ^Ar^vU'  Rob-  Pean  residents,  are  the  host  of  this  parasite.     It  resides  in 
ertsoru  the    connective  tissue,  and   apparently  has   the  habit  of 

wandering  all  over  the  body.  Sometimes  a  little  local 
swelling  and  irritation  indicate  the  presence  of  the  worm  in  a  finger ;  at 
another  time  a  similar  local  swelling  and  irritation  show  that  it  has 
travelled  to  the  forearm  or  elsewhere.  A  favourite  resort  of  the  parasite 
is  the  subcutaneous  fascia  about  the  orbit,  and  not  infrequently  the  sub- 
conjunctival connective  tissue.  When  traversing  the  latter,  the  worm  is 
plainly  visible  as  it  wriggles  across  the  ball  of  the  eye. 

The  female  loa  (30  to  40  mm.)  is  considerably  larger  than  the  male 
(25  by  0-3  mm.).  In  both  sexes  the  integument  is  studded  with 
numerous  minute  hemispherical  bosses.  The  tail  of  the  male  is  incurvated, 
and  carries  two  short  unequal  spicules  and  five  pairs  of  caudal  papilla?. 
The  uterus  of  the  female  contains  a  crowd  of  sheathed,  sharp-tailed 
embryos  closely  resembling  F.  nocturna  and  diarna.  In  what  way  the 
embryos  escape  from  the  human  body  has  not  yet  been  ascertained. 
Although  they  have  been  sought  for  in  the  blood  at  all  hours  of  the  day 
and  night,  and  in  apparently  suitable  cases,  hitherto  they  have  not  been 
found  in  the  circulation.  The  life-history  of  this  parasite  is  quite 
unknown. 

When  a  loa  visits  the  eye,  its  presence  may  give  rise  to  considerable 
irritation,  so  that  its  removal  is  desirable.  This  is  easily  effected  by 
cocainising  the  eye,  at  the  same  time  seizing  the  conjunctiva  and 
subjacent  worm  with  fixation  forceps.  The  conjunctiva  is  then  snipped  or 
incised,  and  the  worm  withdrawn.  In  the  event  of  a  loa  presenting  under 
the  skin  elsewhere,  doubtless  a  hypodermic  injection  of  bichloride  of 
mercury  solution  (1  in  1000),  made  in  the  same  way  as  for  guinea-worm, 
would  prove  an  efficient  parasiticide. 


NEMATODA.  557 

Ehabdonema  intestinale  is  an  intestinal  nematode,  found  in  many  warm 
countries,  especially  in  diarrhoeic  conditions,  and  in  association  with 
A.  duodenale.  It  is  very  minute,  2  by 
0-04  mm.  Its  young,  formerly  known 
as  Anguillula  stercoralis  (Fig.  88),  are 
hatched  out  in  the  intestine  of  the  host, 
and   appear    in   the    faeces    as    actively  Fl(;-  88.— Embryo   Ehabdonema  intes- 

v  1  ,    -i     n         i  t,    ■    ,  linale    in    feces. — After    Gol^i    aud 

wriggling,  sharp-tailed  embryos.    li.tntes-      Monti 

tinale  appears  to  be  innocuous. 

Filaria  sanguinis  hominis. — The  young  of  at  least  four  species  of 
filarial  occur,  as  a  normal  feature  in  their  life  histories,  in  the  human 
blood.  They  have  been  named  F.  nocturna,  F.  diurna,  F.  perstans, 
and  F.  demarquaii.  Besides  these,  another  form,  closely  resembling 
F.  demarquaii,  has  been  found  under  circumstances  which  make  it 
possible  that  it  belongs  to  an  additional  and  independent  species.  On 
this  assumption  I  have  named  this  blood  worm,  provisionally,  F.  ozzardi. 
An  adult  filaria  (F.  magalhcesi)  has  also  been  found  in  the  blood ;  so 
far  it  is  impossible  to  be  certain  that  this  is  not  the  adult  form  of  F. 
demarquaii. 

The  hsematozoal  filaria  embryos,  though  closely  resembling  each 
other,  are  nevertheless  distinguishable  by  peculiarities  in  their  morpho- 
logical and  physiological  details.  They  are  all  of  them  long,  sinuous, 
snake-like,  extremely  active  organisms,  ranging  in  size,  according 
to  species,  from  yl-g-  in.  to  TXT  in.  in  length,  by  5  -^  0-  in.  to  s<?0()  in. 
in  breadth.  In  shape  they  are  cylindrical,  tapering  posteriorly,  and 
being  somewhat  abruptly  rounded  off  anteriorly.  Their  transparent 
bodies  consist  of  a  delicately  transversely  striated,  musculo-cutaneous 
structure  enclosing  a  column  of  minute  cells,  in  the  continuity  of  which 
various  interruptions  can  be  made  out  in  stained  specimens,  and  also, 
though  less  readily,  in  the  living  and  unstained  animal.  One  of  these 
interruptions  near  the  anterior  end  has  been  named  the  "  V  spot " ;  a 
second,  about  the  middle  of  the  worm,  and  apparently  produced  by  a  long 
caecal  vessel,  the  "  central  viscus  "  ;  and  a  third  close  to  the  tail,  the  "  tail 
spot." 

F.  nocturna  (Fig.  89)  (F.  sanguinis  hominis  of  Lewis),  and  the  diseases 
it  gives  rise  to,  are  found  in  the  tropics  and  sub-tropics.  In  some  places 
it  is  rare,  whilst  in  others  it  is  present  in  from  10  to  50  per  cent,  of 
the  population,  its  occurrence  depending  on  the  hydraulic  conditions, 
the  habits  of  the  people,  and  the  distribution  of  certain  species  of 
mosquito.  It  measures  TXT  in.  by  ^-oVo-  m-  to  3-5V0  m-»  and  ^s  enclosed  in 
a  very  delicate,  transparent,  structureless  sheath,  which,  being  consider- 
ably longer  than  the  little  animal  it  contains,  dangles  from  head  or  tail, 
according  to  the  degree  of  contraction  or  extension,  and  to  the  position 
for  the  time  being  of  the  body  of  the  worm.  The  head  end  exhibits  a 
peculiar  movement  produced  by  the  retraction  and  protraction  of  a  six- 
lipped  prepuce  and  of  a  minute  spine. 

It  is  the  habit  of  this  worm  to  frequent  the  peripheral  circulation 
only  during  the  night  (hence  its  name).  Beginning  to  appear  in  the  super- 
ficial capillaries  about  five  or  six  in  the  evening,  it  increases  in  numbers  up 
to  midnight,  diminishes  in  numbers  towards  morning,  and  disappears 
for  the  day  about  8  or  9  a.m.     During  the  day,  as  has  been  ascertained 


553 


DISEASES  CA  USEE  BY  ANIMAL  PARASITES. 


by  post-mortem  examination,  it  retires  to  the  lungs  and  larger  arteries, 
where  at  that  time  it  may  be  found  in  prodigious  numbers.  This  pheno- 
menon of  diurnal  appearance  and  disappearance  has  been  named  "  filarial 
periodicity." 

Filarial  periodicity  is  an  adaptation  of  the  habits  of  the  filaria  to  those 
of  particular  species  of  mosquito  which  act  as  its  intermediate  host.  The 
female  mosquito  in  feeding  sucks  up  the  filaria  with  the  blood.  So  soon  as 
the  parasite  finds  itself  in  the  stomach  of  the  mosquito,  it  quits  its  sheath, 
thereby  uncovering  the  cephalic  armature  alluded  to ;  by  means  of  this 
armature  it  is  enabled  to  travel  into  the  thoracic  muscles  of  the  insect. 
Arrived  there,  and  lying  passively  between  the  muscular  fibres,  it  undergoes 
a  metamorphosis  which  eventuates  in  the  elaboration  of  an  alimentary  canal, 

a    four-lipped    mouth,   a 
three-lobed   caudal    end, 
great    increase    in     size 
(-Jq-  in.),  and    eventually 
renewed     activity".      The 
filaria  now  quits  the  tho- 
racic muscles, and,  passing 
»\    forwards,    traverses    the 
prothorax    and   neck  of 
the   insect,  coiling  itself 
up  in  the  head  just  under 
the  brain  and  at  the  base 
of  the  proboscis.     Thence 
from  the  sixteenth  to  the 
twentieth   day  it   passes 
into     the    proboscis,    by 
means    of    which    it    is 
doubtless    inserted    into 
the   tissues  of  a  human 
host,  when  the  mosquito 
next     feeds    on    human 
160.)      blood.       It    is    possible, 
though  not  likely,  that  a 
few  of  the  metamorphosed  filaria?  escape  into  water,  and  in  this  medium 
reach  man.    Arrived  in  man,  the  parasite  passes,  by  penetrating  the  tissues, 
to  its  permanent   habitat — the  lymphatic  trunks;   here  it  grows  into  a 
sexually  mature  nematode  (F.  hancrofti)   and   in    due   course,  after  im- 
pregnation, emits  its  young — F.  noctuma.     The  young,  after  passing  along 
the  lymphatics,  appear  in  the  blood. 


Fig.  89. — Filaria  sanguinis  hominis  noctuma. 


F.  bancroftt  is  a  long,  slender,  filiform  worm,  in  appearance  like  a 
white  horse-hair.  When  newly  removed  from  the  body,  it  exhibits  active 
wriggling  movements.  Its  surface  is  smooth.  The  head  is  somewhat 
club-shaped,  and  is  unarmed,  having  a  punctiform  mouth  at  its  centre. 
The  female  worm  is  the  larger,  being  3  to  4  in.  in  length  by  about 
0T85  mm.  in  breadth ;  the. male  is  2  to  3  in.  in  length  by  "1  mm.  in  breadth. 
In  both  sexes  the  tail,  after  tapering  somewhat,  is  abruptly  rounded  off, 
the  anus  being  subterminal.  In  the  female  the  vagina  opens  a  short 
distance  (12  mm.)  behind  the  head.  The  tail  of  the  male  is  provided 
with  two  unequal  spicules ;  so  far,  no  caudal  papilla?  have  been  made 
out. 


NEMATODA.  559 

Ordinarily  these  parasites  give  rise  to  no  disease.  Occasionally, 
however,  particularly  when  present  in  large  numbers,  when  unfortunately 
located,  or  when  injured,  they  prove  pathogenic.  The  young  (F.  nocturna), 
in  many  instances,  are  present  in  prodigious  numbers;  as  many  as  500  or 
600  have  been  counted  in  a  drop  of  blood.  In  such  cases,  large  numbers  of 
mature  worms  (F.  bancrofti)  have  been  found  in  the  lymphatics.  The 
young  circulate  freely,  and  do  no  harm  to  their  human  host ;  the  mature 
parasite  alone  is  pathogenic. 

F.  bancrofti  gives  rise  to  disease  in  three  different  ways.  Sometimes, 
apparently  in  consequence  of  its  death,  it  causes  abscess — filarial  abscess. 
Sometimes,  by  blocking  the  large  lymphatic  trunks,  particularly  the 
thoracic  duct,  it  dams  up  the  lymph  stream ;  it  thereby  causes  dilatation  of 
the  vessels  in  the  implicated  area,  necessitating  regurgitation  of  the 
contents  of  the  thoracic  duct  through  a  compensatory  anastomosis.  Per- 
manent varicosity — lymphatic  varix — ensues.  These  varices  sometimes 
rupture.  If  the  varix  happens  to  involve  the  urinary  bladder,  kidneys, 
or  ureters,  and  rupture  occurs,  the  contents  of  the  varix  escape  into  the 
urine,  and  chyluria  is  the  result.  If  the  varix  involves  the  scrotum, 
lymph  scrotum  is  produced.  This  is  a  sort  of  soft  elephantoid  thick- 
ening of  the  scrotum,  the  surface  of  which  is  studded  with  dilated 
lymphatics,  which  are  prone  to  rupture  spontaneously  or  as  a  result  of  in- 
jury. If  the  varix  involves  the  groin  glands,  certain  peculiar,  soft,  doughy 
swellings,  apt  to  be  mistaken  for  hernia,  are  formed — varicose  groin  glands. 
Lymphatic  varices  may  form  in  other  parts,  as  the  legs,  or  surface  of  the 
abdomen;  should  the  varices  rupture,  they  lead  to  permanent  or  inter- 
mitting lymphorrhagia.  Tumours  similar  to  those  in  the  groin  may  form 
in  the  axillre.  Occasionally  somewhat  similar  but  evanescent  swellings, 
caused  by  temporary  blocking  of  the  lymphatics  by  the  parent  worms,  may 
appear ;  such  occur  more  especially  on  the  arms.  Chylous  dropsy  of  the 
tunica  vaginalis  is  an  occasional  result  of  rupture  of  a  filarial  varix  in 
that  situation.  These  various  varices  are  apt  to  inflame,  but  they  rarely 
suppurate.  The  symptomatic  fever  is  very  often  acute,  tends  to  recur 
at  uncertain  intervals,  has  a  well-marked  initial  rigor,  followed  by  severe, 
hot,  and  sweating  stages ;  it  is  apt  to  be  mistaken  for  malarial  fever. 
With  care  a  correct  diagnosis,  based  on  the  concurrent  lymphangitis, 
should  be  easily  made. 

There  are  strong  reasons  for  believing  that  tropical  elephantiasis 
arabum  also  is  caused  by  F.  bancrofti;  but  the  modus  operandi  of  the 
parasite  in  giving  rise  to  the  various  forms  of  this  condition  is  not  so 
obvious.  It  seems  probable  that  the  lymphatic  obstruction  which 
eventuates  in  the  elephantiasis,  is  caused  by  embolic  plugging  of  the 
afferent  lymphatics  of  the  glands  by  ova  prematurely  emitted  by  a  para- 
site that  has  been  injured  by  a  blow  or  otherwise.  The  ovum  is  of  much 
greater  diameter  than  the  embryo  filaria,  and  consequently  cannot  pass 
the  glands.  This  embolism  gives  rise  to  lymph  stasis,  which,  if  the  impli- 
cated part  become  inflamed  through  injury  or  septic  infection,  gradually 
leads  to  hypertrophy  of  the  implicated  integuments.  The  blocked 
lymphatics  are  incapable  of  removing  the  effused  inflammatory  products. 
Recurring  attacks  of  lymphangitis  and  associated  erysipelatoid  inflam- 
mation may  thus  gradually  build  up  an  enormous  swelling.  In  conse- 
quence of  the  lymphatic  area  containing  the  parasites  being  cut  of  by  the 
embolic  plugging  of  the  glands,  the  embryos  of  the  worm  which  had 
wrought  the'original  mischief  cannot  enter  from  the  blood ;  consequently, 


560  DISEASES  CAUSED  BY  ANIMAL  PARASITES. 

elephantiasis  arabum,  although  probably  caused  by  the  filaria,  is  not 
generally  associated  with  the  presence  of  F.  nocturna  in  the  circulation. 
On  the  other  hand,  the  way  to  the  blood  being  still  open  in  chyluria, 
lymph  scrotum,  varicose  groin  glands,  and  other  forms  of  filarial  varix,  in 
these  diseases  F.  nocturna  is  generally  to  be  found  in  the  circulation. 
Occasionally,  in  cases  of  long  standing,  although  the  disease  persists,  the 
parasites  die  out. 

In  chyluria  the  patient  passes  a  milky-looking,  pinkish,  or  sanguino- 
lent,  opaque  urine,  which  usually  sets  into  a  blancmange-like  jelly.  The 
clot  so  formed  gradually  contracts,  a  scanty  reddish  deposit  falling  to  the 
bottom,  and  a  cream-like  pellicle  forming  on  the  surface  of  the  urine 
on  standing.  Oil  globules,  lymph  corpuscles,  and  perhaps  red  cor- 
puscles like  those  of  blood,  are  present  in  abundance,  and  very  frequently 
filarial  are  found  in  the  deposit,  or  entangled  in  the  fibrinous  coagulum. 
The  urine  contains  large  quantities  of  albumin.  This  condition  is  liable 
to  come  and  go  at  uncertain  intervals,  and  to  persist  for  hours,  days,  or 
months  at  a  time.  The  appearance  of  chyle  in  the  urine  is  generally 
preceded  by  aching  in  the  loins  and  pelvis,  and  other  sensations 
evidently  symptomatic  of  distension  by  accumulated  chyle  and  lymph 
in  the  enormous  lymphatic  varix  which  dissection  has  shown  to  be 
present  in  the  abdomen  and  pelvis  in  this  as  well  as  in  lymph  scrotum, 
varicose  groin  glands,  and  other  forms  of  filarial  varix.  Coagulation  of 
chyle  in  the  bladder  sometimes  causes  retention  of  urine  calling  for 
catheterism.  Chyluria  is  rarely  directly  fatal ;  but  it  is  apt,  if  prolonged 
and  excessive,  to  drain  the  patient  and  give  rise  to  anaemia,  debility, 
and  great  mental  depression. 

Treatment. — Many  drugs  have  been  vaunted  as  efficacious,  but  it  is 
questionable  if  any  medicinal  substance  can  control  lymphorrhagia  from  a 
gaping  lymphatic  in  the  urinary  tract.  Tincture  of  the  perchloride  of 
iron,  tannic  acid,  gallic  acid,  salol,  salicylate  of  soda,  benzoic  acid,  ichthyol, 
chromic  acid,  methylene-blue,  have  all  been  recommended.  To  be  of  any 
sendee,  it  is  evident  that  these  drugs  must  be  given  in  full  doses.  By  far 
the  most  effectual,  as  well  as  rational,  way  of  treating  chyluria  is  to  send 
the  patient  to  bed  and  to  insist  on  his  keeping  the  recumbent  position 
with  the  pelvis  elevated ;  to  place  him  on  low  diet,  and  to  stop  all  fats 
and  other  chyle-forming  foods ;  to  restrict  the  amount  of  fluid ;  to  purge 
gently  with  a  saline  ;  and  to  adopt  such  other  measures  as  would  be  likely 
to  lessen  fluid  pressure  in  the  tense  and  leaking  lymphatics. 

The  subjects  of  chyluria,  and  of  the  various  other  forms  of  filarial 
varix,  should  avoid  all  violent  efforts  such  as  are  likely  to  lead  to  rupture 
of  the  engorged  and  thinned  vessels.  Pregnancy  is  prone  to  induce  chyluria 
in  filarial  patients.  Lymph  scrotum  and  varicose  groin  glands  should  be 
excised  if  troublesome.  It  is  well  to  bear  in  mind  tbat  their  removal  must 
increase  the  lymph  pressure  in  the  remainder  of  the  lymphatic  anastomoses, 
and  therefore  may  eventuate  in  chyluria  or  in  elephantiasis  of  a  leg.  These.. 
as  all  forms  of  filarial  disease,  do  best  in  cold  climates. 

In  elephantiasis  arabum  there  is  a  thickening  of  the  skin  and  sub- 
cutaneous fascia,  resulting,  as  explained,  from  imperfect  absorption  of 
inflammatory  products  in  a  lymphatic-blocked  area.  The  disease  is  very 
common  in  countries  in  which  F.  nocturna  is  also  common.  It  is  per- 
manent, and  tends  to  increase  from  recurrences,  at  longer  or  shorter 
intervals,  of  the  inflammation,  each  attack  adding  a  little  to  the  bulk  of 
the  mass.     The  surface  of  the  affected  part  becomes  rough  and  glabrous. 


NEMATODA 


5^i 


The  derma  is  dense,  unyielding,  and  greatly  hypertrophied  ;  whilst  the  sub- 
cutaneous fascia  is  converted  into  a  lax,  blubbery-looking,  dropsical  tissue, 
traversed  by  irregular  fibrous  bands.  The  lymphatics  are  enlarged,  the 
lymphatic  glands  hypertrophied  and  indurated.  The  arteries  and  veins 
may  also  be  increased  in  size ;  and  there  may  be  various  pressure  changes 
in  nerves,  muscles,  and  bones.  The  parts  most  usually  affected  are  the 
legs,  one  or  both ;  the  scrotum,  which  may  attain  enormous  dimensions ; 
the  labia ;  more  rarely  the  arms  are  attacked ;  and,  still  more  rarely, 
the  mammas  and  isolated  skin  areas. 

In  the  case  of  the  legs  and  arms,  elastic  bandaging,  elevation,  and 
massage  may  help  to  keep  the  swelling  under.  When  the  scrotum,  labia,  or 
mammas  are  seriously  and  inconveniently  involved,  they  should  be  removed. 

The  prophylaxis  of   this   as    of   all    filaria   disease  lies   in  protection 
from  mosquito  bite  and 
in   the   suppression    of 
these  insects. 

F.  diurna.  —  Mor- 
phologically indistin- 
guishable from  F.  noc- 
turna,  this  hsematozoon 
is,  nevertheless,  an  in- 
dependent species.  F. 
diurna  appears  in  the 
peripheral  circulation 
during  the  day  only ; 
a  physiological  feature 
exactly  the  opposite 
to  the  corresponding 
phenomenon  in  F.  noc- 
turna,  and  one  point- 
ing to  a  different  inter- 
mediate host.  It  seems 
to  be  very  common  on 
the  lower  Niger  and 
adjacent  countries.  The 
parental  form  is  unknown;  equally 
conditions. 


Fig.  90. — Filaria  sanguinis  Jiominis  perstans.     (x  160.) 


so    the    associated    pathological 


F.  perstans. — Shorter  and  more  slender  (0-23  by  0-0045  mm.)  than 
the  preceding  parasites,  F.  perstans  further  differs  in  not  possessing  a 
sheath,  in  having  a  truncated  tail,  in  being  endowed  with  locomotive 
habits  as  well  as  with  remarkable  powers  of  retraction  and  extension, 
and  also  in  not  exhibiting  a  diurnal  periodicity. 

F.  perstans  appears  to  be  confined  to  certain  extensive  tracts  in  West 
Africa — particularly  the  Congo  basin,  where  it  is  present  in  many  places  in 
quite  50  per  cent,  of  the  native  population.  I  have  also  seen  it  in  Europeans 
who  had  resided  in  that  country.  It  occurs  in  Guiana  (see  F.  ozzardi). 
The  parental  form  resembles  F.  bancrofti,  Very  little  is  known  of  its  patho- 
logical bearings.  From  the  concurrence  of  their  respective  geographical 
ranges,  and  from  other  circumstances,  it  has  been  conjectured  that  F. 
perstans  may  in  some  way  be  responsible  for  that  singular  West  African 
disease — sleeping  sickness. 
vol.  1. — 36 


562  DISEASES  CAUSED  BY  ANIMAL  PARASITES. 

F.  demarquaii  in  size  and  habit  resembles  F.  perstans.  It  differs, 
however,  from  the  latter  in  anatomical  characters,  the  tail  being  sharply 
pointed.  In  fact,  F.  demarquaii  is  like  a  diminutive  F.  noctuma  without 
the  sheath  and  diurnal  periodicity.  Hitherto  it  has  been  found  only  in 
the  West  Indies — St.  Vincent  and  St.  Lucia.  Possibly  it  occurs  in 
British  Guiana,  New  Guinea,  and  West  Africa.  The  parental  form  has 
not  been  identified  with  certainty.  So  far  as  known,  F.  demarquaii  gives 
rise  to  no  disease. 

F.  ozzardi. — The  blood  in  over  50  per  cent,  of  the  aboriginal  Indians  of 
British  Guiana  has  been  found  to  contain  two  minute  filarial  embryos — 
one  morphologically  identical  with  F.  perstans,  the  other  with  F.  demar- 
quaii. From  the  circumstance  that  the  two  forms  are  almost  invariably 
in  association  in  the  same  host,  it  was  at  one  time  considered  that  they 
might  be  the  offspring  of  the  same  parental  form ;  in  which  case,  seeing 
that  the  tail  of  F.  perstans  is  invariably  truncated,  and  that  of  F.  demar- 
quaii invariably  sharp,  they  must  belong  to  quite  another  species.  Lately, 
however,  Daniels  of  Demerara  has  found  in  these  Guiana  cases  two 
absolutely  different  parental  forms,  in  the  uterus  of  one  of  which  he  found 
only  blunt-tailed  embryos,  whilst  in  the  uterus  of  the  other  he  found  only 
sharp-tailed  embryos.  Until,  therefore,  the  parental  forms  of  the  African 
F.  perstans  and  of  the  West  Indian  F.  demarquaii  have  been  identified,  we 
cannot  be  sure  that  the  two  embryonic  forms  indicated  by  the  provisional 
name  F.  ozzardi  are  not  one  or  other  of  these  parasites. 

The  parental  forms  referred  to  were  found  in  the  mesentery,  beneath 
the  peritoneum,  and  in  the  subpericardial  fat.  In  general  shape  and 
structure  they  resemble  F.  bancrofti,  but  differences  in  measurement  and 
anatomical  detail  plainly  indicate  that  they  are  not  this  parasite.  The 
parental  form  of  the  blunt-tailed  embryo  measures  in  the  case  of  the 
female  70  to  80  mm.  in  length  by  0-12  mm.  in  breadth ;  in  the  case  of  the 
male,  45  mm.  in  length  by  0-064  mm.  in  breadth.  The  female  parent  of 
the  sharp-tailed  embryo  measures  280  mm.  in  length  by  0*45  mm.  in 
breadth  ;  the  male  has  not  been  described.1 

Hitherto  no  pathological  condition  has  been  recognised  as  depending 
on  these  parasites. 

F.  megalhasi. — The  mature  form  of  this  parasite  was  found  in  Brazil 
in  the  left  ventricle  of  a  child,  and  was  doubtless  associated  with  htema- 
tozoal  embryos;  the  latter  were  not  described.  The  dimensions  of  the 
parasites  were  as  follows : — Female,  155  by  0*66  mm. ;  male,  83  by  0-25  mm. 

PATRICK  ALAXSOX. 

1  Since  the  above  was  ■written,  I  have  found  the  parental  form  of  F.  perstans.  On  com- 
paring this  with  Daniel's  parental  form  of  the  British  Guiana  blunt-tailed  embryo,  I  find 
them  to  be  identical. 


SECTION    III. 

DISEASES   CAUSED   BY   CHEMICAL 

SUBSTANCES. 


LEAD  POISONING. 

Poisoning  by  metallic  lead,  apart  from  the  inhalation  of  its  fumes 
during  the  act  of  smelting,  is  rare  except  in  the  case  of  file-cutters.  It 
is  generally  due  to  one  or  other  of  its  salts.  Lead  poisoning  is  described 
under  many  names,  e.g.  plumbism,  saturnine  poisoning,  colica  pictonum, 
and  colica  pictorum. 

History. — -The  use  of  lead  has  long  been  known.  The  recent  finds  of 
bars  of  lead  in  Derbyshire  and  Shropshire,  stamped  with  the  imperial 
arms  of  Eome,  show  that  the  early  invaders  of  Britain  were  quite  familiar 
with  the  metal.  Mention  is  made  in  the  writings  of  Galen  and  Vitruvius 
of  drinking-water  when  conducted  through  lead  pipes  acquiring  hurtful 
properties,  and  from  this  we  infer  that  plumbism  not  only  existed  in  the 
early  part  of  the  Christian  era,  but  that  one  of  its  causes  was  distinctly 
recognised.  One  Eoman  architect,  we  are  told,  thus  interdicted  the  use  of 
lead,  a  proscription  which  to-day  is  as  much  called  for  as  then,  seeing  how 
frequently  plumbism  has  arisen  among  dwellers  in  towns  from  drinking 
water  conveyed  through  lead  pipes.  In  the  five  years  ending  1890,  there 
occurred  1822  deaths  from  accidental  poisoning  in  England  and  Wales, 
and  of  these  541,  or  29  per  cent.,  were  due  to  lead.  During  the  five  years 
ending  1895,  plumbism  caused  672  deaths  in  England  and  Wales. 

Lead  is  a  subtle  poison.  So  numerous  are  the  sources  of  the  poison, 
and  so  gradually  is  the  health  undermined  by  it,  that  it  is  not  until  in 
some  instances  his  constitution  is  profoundly  affected  by  it  that  the 
individual  is  aware  of  what  has  taken  place.  The  outbreaks  of  plumbism 
in  some  of  our  large  towns,  and  the  extent  to  which  serious  illness  occurs 
among  workers  in  white-lead  factories,  alike  demonstrate  the  fact  of  the 
slow  but  sure  operation  of  the  poison.  It  is  with  lead  as  with  most 
poisons — all  into  whose  system  it  has  gained  entrance  do  not  suffer  equally. 
There  is  an  individual  and  a  family  predisposition  to  plumbism,  and  to 
these  might  be  added  a  sexual  proclivity,  for  women,  especially  young 
women,  seem  to  suffer  more  readily  than  men.  A  gouty  diathesis  pre- 
disposes to  it,  also  poverty,  alcoholic  intemperance,  and  want  of  personal 
cleanliness  on  the  part  of  lead  workers. 


564       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

Etiology. — It  is  unnecessary  to  enumerate  at  length  all  the  sources 
of  lead  poisoning.  Of  these  the  principal  are — (1)  Contamination  of  the 
drinking-water  at  the  gathering  ground  or  in  its  transit,  whereby,  owing 
to  certain  physico-chemical  changes  having  been  induced  in  the  water,  its 
plumbo-solvency  is  increased,  and  (2)  working  among  lead  or  its  salts. 
The  presence  of  a  trace  of  iron  or  of  nitrogenous  compounds  in  water  im- 
parts a  plumbo-solvent  influence,  which  renders  the  water  dangerous  for 
human  use  if  drawn  through  lead  pipes. 

The  presence  of  lime  salts  in  water  prevents  to  some  extent  the 
interior  of  a  lead  pipe  being  injuriously  acted  upon  by  water,  for  an 
insoluble  carbonate  of  lead  is  thus  formed  and  deposited  upon  the 
metal.  This,  however,  is  readily  dissolved  by  water  containing  the 
slightest  trace  of  acidity,  even  carbonic  acid  itself.  New  lead  pipes 
are  more  quickly  influenced  than  those  that  have  been  in  use  for  a  time, 
and  the  same  remark  applies  to  a  pipe  made  of  lead  from  which  all  the 
silver  has  been  abstracted  ;  hence  there  is  less  danger  in  using  pipes 
made  from  British  lead  than  those  from  foreign  ore.  All  these  facts 
demonstrate  how  unwise  it  is  for  us  to  have  our  drinking-water  conveyed 
through  lead  pipes  or  stored  in  lead  cisterns,  and  the  advisability  of 
replacing  this  metal  by  some  substitute  such  as  iron  or  by  glass-lined  lead 
pipes.  The  presence  of  even  very  minute  quantities  of  lead  in  drinking- 
water  is  dangerous,  for  experience  has  shown  that  plumbism  is  less  due 
to  the  entrance  into  the  system  of  one  or  two  large  doses  of  a  lead  salt,  than 
to  the  continued  entrance  of  very  minute  quantities  over  a  lengthened 
period.  Health  may  be  lost  by  a  person  repeatedly  drinking  water  that 
contains  only  y^-nth  to  j^th  of  a  grain  of  lead  per  gallon.  In  one  of  my 
own  cases  severe  symptoms  followed  the  use  of  water  which  contained 
'0028  gr.  of  lead  per  gallon.  It  is  not  necessary  that  the  lead  should  be 
in  solution.  Some  time  ago  I  saw,  in  consultation,  a  lady  who  was 
suffering  from  a  severe  form  of  lead  poisoning,  due  to  a  careless  workman 
having  left  in  the  cistern  several  lumps  of  white-lead.  In  Queensland, 
epidemics  of  lead  poisoning  have  been  traced  to  the  use  of  water  that  has 
been  stored  in  galvanised  iron  tanks. 

Of  all  our  industries  it  is  the  white-lead  factories  that  supply  the 
largest  number  of  cases,  and  the  most  serious  types,  of  plumbism.  In  this 
country  the  manufacture  of  white-lead  is  carried  on  by  what  is  known  as 
the  old  Dutch  process.  The  product  thus  obtained  is  renowned  for  its 
purity  and  whiteness.  It  is  during  the  emptying  of  the  "  white  beds,"  and 
more  particularly  the  drying  of  the  white-lead  in  what  is  called  the 
"stoves,"  that  the  factory  worker,  inhaling  the  fine  dust  suspended  in  the 
atmosphere,  is  most  prone  to  become  affected.  Six  weeks  spent  in  this 
occupation  have  to  my  knowledge  proved  fatal  to  young  women. 

The  Potteries  of  Staffordshire  have  for  long  had  an  unenviable  reputa- 
tion for  lead  poisoning.  Girls  employed  as  "  dippers'  assistants "  and 
"  brushers  off,"  also  colourers  and  majolica  paintresses,  frequently  become 
paralysed  and  blind.  It  is  estimated  that  300  to  400  cases  of  plumbism 
occur  in  the  Potteries  annually.  Painters,  too,  are  peculiarly  prone  to 
lead  colic.  Stiihler  of  Berlin,  who  draws  his  statistics  of  plumbism  from 
the  reports  of  sick  benefit  societies,  states  that  of  3000  painters  in  Berlin 
313  were  annually  sick  from  this  cause,  equal  to  10*4  per  cent.  Gautier 
found  in  Paris  that  out  of  14,000  painters  and  varnishers,  on  an  average 
250  visited  the  hospitals  on  account  of  lead  poisoning,  and'  an  equal 
number  received  treatment  at  home,  giving  a  percentage  of  3-5. 


LEAD  POISONING.  565 

Printers'  compositors  have  for  long  been  known  to  suffer  from  plumbism, 
but  whether  this  is  due  to  absorption  through  the  skin  by  handling  the 
type,  which  contains  lead,  and  becomes  oxidised  during  wear,  or  is  swallowed 
by  eating  with  unwashed  hands,  has  not  been  definitely  settled.  Fromm 
discusses  the  question,  and  alludes  to  Stumpfs  analysis  of  the  dust  of 
printing-houses,  which  he  found  contained  as  much  as  14'43  per  cent,  of 
lead.  In  a  recent  report  to  the  German  Board  of  Health,  Faber  states 
that  he  found  in  the  dust  collected  from  the  floor  11/51  per  cent.,  on  a 
shelf  in  the  room  6-59  per  cent.,  and  in  the  gangway  between  the  desks  in 
the  composing-room  of  a  newspaper  office  4-7  per  cent,  of  lead.  Inhalation 
of  the  dust  of  the  oxidised  metal  in  all  probability,  therefore,  plays  the  more 
important  part  in  the  causation  of  plumbism  among  compositors. 

The  use  of  canned  foods,  too,  especially  fruits,  is  a  source  of  plumbism. 
As  a  result  of  the  action  of  natural  acids  upon  the  tin  or  solder,  lead  is 
dissolved  out  and  can  be  readily  detected  in  the  syrup.  A  child  died  after 
eating  tinned  sardines,  and  in  the  internal  organs  of  the  victim,  as  well  as 
in  the  oil  and  sardines,  Lowry  of  Baltimore  found  lead.  Canned  pears  and 
apricots  show  the  greatest  amount  of  dissolved  lead,  pine-apples  the  least. 

Lead  gains  entrance  into  the  system  through  —  the  respiratory 
passages,  by  inhalation  of  the  fumes  during  the  smelting  of  the  ore,  or  by 
breathing  an  atmosphere  rendered  dusty  by  the  presence  of  lead  salts ; 
through  the  gastro-intestinal  tract,  by  food  and  drink  having  been  contam- 
inated, or,  in  the  case  of  the  lead  worker,  by  eating  with  unwashed  hands  ; 
and  through  the  skin  when  perspiring.  Of  these  channels  entrance 
by  the  respiratory  passages  is  very  important,  also  entrance  by  the 
stomach,  the  hydrochloric  acid  of  the  gastric  juice  converting  any  in- 
soluble lead  salts  into  the  soluble  chloride,  which  is  readily  absorbed. 
Lead  is  eliminated  from  the  system  by  the  kidneys  and  bowels ;  also  by 
the  skin,  and  occasionally  by  the  milk. 

Morbid  anatomy  and  pathology. — Acute  plumbism. — The 
morbid  anatomy  of  acute  plumbism  is  practically  nil.  After  death  from 
lead  encephalopathy,  beyond  the  brain  being  found  shrunken,  firm,  and 
dry,  or  extremely  pale  and  watery,  as  in  ursemic  poisoning,  the  cerebrum 
may  present  nothing  unusual.  On  chemical  analysis,  lead  may  be  detected 
in  the  brain ;  in  some  of  my  own  cases  it  was  absent.  Lead  is  also  found 
in  the  liver,  kidneys,  and  bones ;  never  in  the  blood  serum,  although, 
according  to  Bin  z,  it  is  said  to  have  been  found  in  the  red  blood  corpuscles. 
The  heart  and  lungs  present  nothing  abnormal;  the  small  intestine  at 
places  is  occasionally  extremely  contracted.  The  kidneys,  on  micro- 
scopical examination,  present  the  appearances  met  with  in  early  parenchy- 
matous nephritis,  namely,  cloudy  and  fatty  changes  in  the  renal  epithelia, 
accompanied  in  more  chronic  cases  by  evidence  of  interstitial  and  glomerular 
nephritis. 

.  Chronic  plumbism. — It  is  in  the  chronic  plumbism  that  the  kidneys 
are  atrophied  and  the  interstitial  tissue  excessive.  The  pathological  changes 
at  first  are  in  the  tubular  epithelium  and  in  or  around  the  glomeruli.  In 
this  view  I  am  supported  by  Charcot  and  Gombault,  who  in  their  experi- 
ments upon  animals  always  found  the  tubular  epithelium  proliferating, 
and  subsequently  in  the  later  stages  the  interstitial  tissue  increased.  Coen 
and  d'Ajutolo  found  the  epithelia  of  the  convoluted  tubules  swollen  and 
disintegrating  as  early  as  the  fifth  day  in  animals  poisoned  by  lead,  and 
only  in  the  later  stages  evidence  of  interstitial  nephritis.  Carl  Hirsch 
has  repeated  these  experiments,  and  he  finds  in  the  early  stages  of  plumbism 


566         DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

the  glomerular  vessels  extremely  full,  the  epithelium  of  Bowman's  capsule 
swollen,  whilst  outside  the  capsule  there  is  an  accumulation  of  small  round 
cells.  In  all  his  cases  there  were  swelling  and  disintegration  of  the  tubular 
epithelium,  hyaline  and  calcareous  tube  casts,  along  with  cellular  infiltra- 
tion between  the  tubules.  The  opinion  that  in  the  early  stages  of  lead 
poisoning,  interstitial  nephritis  is  the  typical  lesion  of  the  kidney,  is  not 
the  one  that  commends  itself  to  me,  nor  to  the  authors  just  mentioned. 
The  primary  changes  are  undoubtedly  epithelial.  The  liver  is  also  the  seat 
of  pathological  changes.  In  the  early  stages  the  hepatic  cells  are  granular, 
and  the  seat  of  fatty  degeneration,  while  later  on  there  is  evidence  of  an 
intercellular  cirrhosis.  On  chemical  analysis,  lead  is  found  most  largely 
in  the  liver.  During  life  the  functional  activity  of  the  kidneys  and  liver 
is  so  impaired  that  animal  poisons  are  retained  in  the  system,  to  the 
influence  of.  which  upon  the  brain  we  must  largely  attribute  the  epileptiform 
seizures.  In  fatal  cases  of  encephalopathy  the  brain  may  be  dry  on  the 
surface,  as  already  stated,  and  its  convolutions  appear  as  if  compressed,  or 
there  may  be  some  subarachnoid  effusion,  but  where  this  is  present  the 
kidneys  are  usually  at  the  same  time  affected. 

Does  the  paralysis  of  lead  poisoning  depend  upon  a  central  or  a  peripheral 
lesion  of  the  nervous  system  ?  Pathological  opinion  is  divided  upon  this 
point.  In  old-standing  cases  of  plumbic  paralysis,  the  peripheral  nerves 
nave  unquestionably  shown  marked  increase  of  their  connective  tissue  with 
atrophy  of  the  nerve  fibres.  In  the  earlier  stages,  Charcot  and  Gombault 
described  the  peripheral  lesion  as  one  of  periaxial  or  segmentary  neuritis, 
meaning  by  that  term  inflammation  only  of  the  medullary  sheath  of  the 
nerve,  for  the  axis  cylinder  is  spared;  hence  their  explanation  of  the  early 
recovery  of  the  loss  of  motion  in  some  cases  of  saturnine  paralysis.  As 
this  segmentary  neuritis  is  found  in  a  large  number  of  infectious  and 
inflammatory  diseases,  its  value  in  lead  poisoning  is  for  that  reason  much 
discounted.  In  a  disease  like  plumbism,  where  paralytic  phenomena 
quickly  develop,  and  occasionally,  though  very  seldom,  just  as  rapidly 
disappear,  the  probability  is  that  the  central  nervous  system  and  not 
the  peripheral  is  to  blame.  At  any  rate  the  spinal  cord  is  not  always 
healthy.  Dejerine  found  changes  in  the  anterior  roots,  similar  to  those 
observed  in  the  peripheral  nerves,  and  in  cases  of  acute  lead  poison- 
ing that  exhibited  paralytic  phenomena,  there  has  sometimes  been 
found  marked  hypereemia  of  the  anterior  cornua  of  grey  matter  of  the 
spinal  cord.  The  large  multipolar  cells  in  the  spinal  grey  matter  are 
probably  so  affected  by  the  toxaemic  blood  in  plumbism,  that  they  fail 
during  life  to  transform  and  transmit  impulses,  without  exhibiting  after 
death  any  noticeable  alteration  of  structure.  In  experimental  plumbism  I 
have  failed  to  detect  evidence  of  peripheral  neuritis  in  the  paralysed  limbs  of 
animals.  My  feeling,  therefore,  is  to  regard  the  ganglion  cells  in  the  spinal 
cord  as  primarily  affected,  and  as  a  consequence  of  the  slight  and  unrecognis- 
able changes  of  structures  therein  established,  the  peripheral  terminations 
of  nerves,  which  are  the  most  vulnerable,  because  they  are  furthest 
removed  from  their  trophic  centres,  either  become  secondarily  affected  or 
fall  a  readier  prey  to  the  action  of  the  toxic  blood.  Fisher  of  New  York 
found  central  as  well  as  peripheral  nerve  changes  in  the  body  of  a 
painter  who  had  suffered  from  repeated  attacks  of  colic,  whose  hands 
were  paralysed,  and  who  died  after  an  epileptiform  seizure.  The  peripheral 
nerves  were  degenerated,  and  the  cord  in  its  upper  dorsal  region  showed 
atrophy  of  the  anterior  cornu  on  one  side,  and  the  antero-lateral  tract  of 


LEAD  POISONING.  567 

the  other,  along  with  sclerosis  of  Goll's  column.  Pal  maintains  that  the 
cells  in  the  anterior  cornua  may  be  affected  in  plumbism,  without  any 
marked  degeneration  observable  in  the  nerve  fibre.  Onuf  reported  the 
case  of  a  painter,  set.  37,  who  had  suffered  from  colic,  paraplegia,  paralysis 
of  flexors  and  extensors  of  left  arm.  At  the  autopsy,  poliomyelitis 
of  the  anterior  cornua  of  spinal  cord,  infiltration  of  the  arterioles  of  the 
cord  with  small  round  cells,  degenerated  anterior  roots,  and  increase  of 
interstitial  tissue  of  the  plantar  nerve,  were  found.  There  is  a  history  of 
traumatism  in  the  case,  which  weakens  the  value  of  the  report.  Mssl, 
Lugaro,  and  Marinesco  found  both  in  lead  and  arsenical  poisoning  that 
the  multipolar  cells  in  the  anterior  cornua  of  the  spinal  cord  were  altered : 
(1)  There  was  a  disappearance  of  the  stainable  substance  of  Nissl  from  the 
dendrites  or  from  the  cell  body ;  (2)  on  the  dendrites  were  nodular  swellings, 
corresponding  to  accumulations  of  stainable  substance ;  (3)  a  tendency  to 
disorganisation  of  individual  Nissl  bodies,  especially  at  the  periphery  of 
the  cell.  Kussmaul  and  Maier  found  hypertrophy  and  sclerosis  of  the 
connective  tissue  of  the  sympathetic  ganglia,  particularly  the  coeliac  and 
upper  cervical,  along  with  induration  and  a  decrease  in  the  cellular 
elements  of  these  organs,  as  a  consequence  of  chronic  plumbism. 

Individuals  who  have  suffered  for  years  from  lead  poisoning  become  old 
prematurely.  If  they  have  escaped  the  paralysis  and  blindness  already 
alluded  to,  they  are  observed  to  be  extremely  cachectic  and  ill-nourished. 
The  face  is  swollen  in  the  morning,  at  night  their  feet  are  cedematous, 
the  urine  contains  albumin  ;  they  suffer  from  shortness  of  breath,  and  they 
either  die  in  ursemic  convulsions  or  from  subacute  inflammation  of  the 
lungs.  At  the  autopsy  the  left  heart  is  found  to  be  hypertrophied ;  there 
is  aortic  valvulitis  with  fibrotic  arteries ;  the  liver  is  shrunken  and  cirrhotic, 
the  kidneys  contracted  and  their  capsule  adherent.  It  is  the  kidneys 
of  these  chronic  cases  that  are  the  seat  of  advanced  interstitial  nephritis. 
In  consequence  of  the  cardio-vascular  and  renal  changes,  the  brain  may 
be  the  seat  of  haemorrhages. 

Sooner  or  later,  as  already  stated,  the  kidneys  become  affected,  and 
albumin  appears  in  the  urine.  It  is  probably  in  consequence  of  failure 
on  the  part  of  the  eliminating  organs  that  many  of  the  severe  nervous 
symptoms  arise.  As  a  rule,  in  the  early  stages  of  plumbism  there  is  no 
albumin  in  the  urine,  but  old  lead  workers  pass  a  urine  which  is  pale  and 
watery,  has  a  low  specific  gravity,  contains  albumin,  and  has  all  the 
physical  and  chemical  characters  observed  in  cases  of  chronic  contracting 
kidney.  Occasionally  there  is  hsemato-porphyrinuria.  The  urine,  which 
may  be  light-coloured  on  being  passed,  becomes  on  standing  cherry-red, 
then  like  light  port  wine,  and  ultimately  very  black.  On  adding  to  it  a 
small  quantity  of  hydrochloric  acid  in  the  cold,  the  urine  gives  the  spec- 
trum of  hsematoporphyrin,  namely,  one  band  in  the  red,  one  in  the  green, 
and  another  to  the  right  in  the  ultra-violet. 

Symptoms. — Abdominal  colic  is  one  of  the  earliest  symptoms. 
Usually  before  abdominal  pain  is  complained  of,  the  face  has  been  ob- 
served to  be  paler,  and  the  patient  has  been  conscious  of  an  increasing 
disinclination  for  food,  and  of  a  disagreeable  taste  in  the  mouth  in  the 
morning.  As  a  rule  the  colic  is  severe  and  recurrent,  and  is  frequently 
associated  with  a  hardened  and  retracted  state  of  the  abdomen,  due  to 
reflex  spasm  of  the  parietal  muscles.  The  pain  is  referred  to  the  neighbour- 
hood of  the  umbilicus,  or  it  is  diffused  over  the  upper  two-thirds  of  the 
abdomen,  and   is  accompanied  by  sickness.     Usually  there   is   obstinate 


568         DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

constipation,  but  there  may  be  diarrhoea.  Even  after  the  bowels  have 
been  freely  opened  by  aperients,  colic  continues,  clearly  indicating 
that  the  pain  is  not  altogether  due  to  constipation.  Pressure  upon  the 
abdomen  sometimes  aggravates,  sometimes  it  relieves,  the  pain.  Some 
patients  obtain  relief  by  firmly  pressing  their  abdomen,  whilst  by  others 
even  gentle  pressure  cannot  be  borne.  It  is  one  of  the  features  of  lead 
colic  that  in  many  cases  the  pain  is  confined  to  one-half  of  the  abdomen, 
or  it  is  worse  in  one-half  than  the  other,  and  that  pressure  aggravates 
it.  Associated  with  this  one-sided  location  of  colic,  I  have  frequently 
noticed  that  considerable  pain  is  also  experienced  when  firm  pressure 
is  applied  to  the  corresponding  side  of  the  neck  along  the  course  of 
the  pneumogastric  nerve,  a  little  above  the  sterno-clavicular  articulation. 
As  the  colic  and  vomiting  subside  and  desire  for  food  returns,  it  is  observed 
that  the  unilateral  colic  and  pain  in  the  neck  disappear  concurrently.  The 
pupils  are  frequently  unequal,  the  pupil  on  the  same  side  as  the  abdominal 
pain  being  usually,  but  not  invariably,  the  smaller.  The  pulses  at  the 
wrist  are  unequal,  the  pulse  on  the  same  side  as  the  colic  being  sometimes 
stronger,  sometimes  weaker,  than  the  other.  What  colic  is  really  due  to  it 
is  difficult  to  say,  but  there  is  evidently  spasm  of  certain  portions  of  the 
small  intestine,  caused  by  the  direct  action  of  lead  upon  the  muscular  fibres 
of  the  intestine,  the  musculature  of  the  intestinal  arteries,  or  upon  the 
nerve  ganglia  and  their  connections.  Although  colic  is  one  of  the  most 
common  symptoms  of  lead  poisoning,  it  is  well  to  remember  that  it  may 
never  appear  during  the  whole  course  of  plumbism.  An  interesting 
phenomenon  observed  in  lead  colic  is  the  occasional  disappearance  of 
sulphocyanide  of  potassium  from  the  saliva,  and  its  return  on  subsidence 
of  the  pain. 

Mouth. — In  old  lead  workers  the  gums  are  ulcerated.  Nearly  all 
patients  exhibit  a  well-marked  blue  line  close  to  the  margin  of  the  gums  and 
teeth,  a  physical  sign  of  considerable  diagnostic  importance,  but  often  absent 
in  young  subjects  whose  gums  are  sound  and  whose  teeth  are  kept  clean  by 
brushing.  For  its  development  it  is  necessary  there  should  be  some  slight 
space  between  the  gums  and  the  teeth  wherein  decomposition  of  albuminous 
food  may  take  place.  This  line  is  due  to  a  deposit  of  sulphide  of  lead  in 
the  deeper  epithelial  and  connective  tissue  cells  of  the  gum  close  to  the 
papillae,  and  does  not  depend,  as  some  have  taught,  upon  embolic  plugging 
of  the  small  blood  vessels  of  the  gum  by  particles  of  sulphide  of  lead. 
Once  developed,  this  blue  line,  first  described  by  Burton,  may  persist  for 
months  in  spite  of  treatment.  I  have  seen  it  disappear  in  from  two 
weeks  to  four  months.  In  lead  workers  sometimes  a  large  blue-black 
patch  can  be  seen  inside  the  lower  lip.  The  surface  of  the  tongue,  too, 
may  be  similarly  discoloured  and  its  papillae  prominent. 

Circulation. — The  pulse  is  frequently  so  small  during  the  attack,  that 
it  can  scarcely  be  felt  by  the  finger  or  even  registered  by  the  sphygmograph, 
but  occasionally  it  is  hard  and  resistant,  indicating  the  coexistence  of 
heightened  arterial  tension  and  abdominal  pain.  Accompanying  the  colic 
there  is  a  marked  fall  in  the  secretion  of  urine,  4  to  8  oz.  only  being 
secreted  per  diem ;  but  beyond  being  scanty  it  is  usually  healthy,  in  first 
attacks  particularly.     The  pulse  rate  may  fall  to  forty  in  the  minute. 

Blood. — The  blood-making  powers  of  a  patient  suffering  from  plumbism 
are  impaired.  The  red  blood  cells  are  numerically  deficient ;  the  thyroid 
gland  is  occasionally  reduced  in  size.  As  lead  is  frequently  present  in  the 
bones,  the  hsematogenic  function  of  bone  marrow  tends  to  become  impaired. 


LEAD  POISONING.  569 

Females  suffer  from  irregular  menstruation.  As  a  rule,  the  menstrual  loss 
is  too  frequent  and  too  profuse,  but  in  a  few  cases  there  is  amenorrhoea. 
Abortion  is  of  common  occurrence  in  female  lead  workers,  and  also  in  the 
lower  animals  that  are  the  subjects  of  experimental  plumbism.  Two 
illustrations  will  suffice.  One  of  my  Infirmary  patients,  a  woman  set.  35, 
had  four  children  at  full  time,  healthy,  and  who  survived.  She  then  went 
to  a  white-lead  factory,  where  she  worked  for  six  years.  During  this 
period  she  had  nine  miscarriages  and  no  living  children.  Another  woman, 
set.  34,  had  four  children  before  becoming  a  lead  worker — two  after- 
wards, and  then  four  miscarriages  in  succession.  So  marked  is  the 
tendency  for  the  lead-tainted  human  female  to  miscarry,  that  in  cases 
where  repeated  abortion  has  taken  place,  the  only  chance  of  such  a 
woman  ever  reaching  the  normal  term  of  pregnancy  and  bringing 
forth  a  living  child  depends  upon  her  leaving  the  white-lead  factory 
altogether.  The  mortality  of  children  born  under  these  circumstances  is 
high ;  most  of  them  die  shortly  after  birth  from  convulsions.  If  a  child 
is  born  alive  to  parents  who  are  both  lead  workers,  it  is  puny  and  ill- 
nourished,  and  generally  dies  a  few  days  after  birth.  In  such  infants  I 
have  found  the  liver,  on  microscopical  examination,  the  seat  of  an  inter- 
cellular cirrhosis,  and  on  chemical  analysis  the  organ  contained  lead. 
When  I  have  administered  lead  to  pregnant  rabbits,  the  metallic  poison 
has  subsequently  been  found  in  the  foetuses,  clearly  indicating  the  ease 
with  which  lead  traverses  the  placenta.  In  the  human  as  in  the  lower 
animals,  it  may  be  owing  to  death  of  the  foetus  as  much  as  to  any  special 
action  of  the  poison  upon  the  uterus,  that  abortion  so  readily  occurs. 
Lead  is  a  strong  ecbolic,  and  is  occasionally  resorted  to  by  women  in  the 
form  of  diachylon  pills,  as  an  abortifacient,  with  direful  results. 

Cerebral. — Headache,  usually  severe,  is  a  common  symptom.  In  acute 
plumbism,  headache  may  be  a  premonition  of  impending  convulsions.  There 
may  be  a  succession  of  epileptiform  seizures,  accompanied  by  loss  of  conscious- 
ness, during  which  the  patient  may  die.  This  is  the  most  serious  form  of 
acute  plumbism,  and  to  it  the  term  "  lead  encephalopathy  "  is  applied.  Asa 
rule,  convulsions  are  preceded  by  such  symptoms  as  headache,  diplopia,  colic, 
and  wrist-drop,  but  these  may  supervene  without  any  premonitory  warning 
beyond  headache.  Occasionally,  young  women  who  are  the  victims  of  lead 
poisoning  are  observed  to  become  changed  in  their  manner ;  they  complain 
of  severe  headache,  and  become  hysterical.  Such  a  combination  of  symptoms 
may  throw  medical  men  off  their  guard.  Too  often  this  toxic  hysteria 
foretells  the  advent  of  epileptiform  seizures,  which  may  prove  fatal  within 
forty-eight  hours.  When  the  convulsions  subside,  the  patient  may  remain 
restless  and  delirious  for  a  time,  and  subsequently  become  melancholic, 
the  spell  of  which  may  be  broken  by  recurrent  mania.  One  of  the  most 
distressing  sequelae  of  saturnine  epilepsy  is  blindness.  The  loss  of  sight 
may  be  complete  and  permanent.  In  a  few  cases  vision  may  be  regained, 
even  after  a  lapse  of  several  weeks. 

A  rare  form  of  paralysis  due  to  lead  is  hemiplegia,  with  or  without 
hemianaesthesia.  I  have  reported  the  case  of  a  man  who  had  right  hemi- 
plegia and  aphasia,  but  in  Da  Costa's  patient,  a  female  who  had  been 
exposed  to  the  odour  of  fresh  paint,  hemiplegia  without  anaesthesia  de- 
veloped in  three  days,  preceded  by  severe  headache,  but  no  colic. 

Symptoms  similar  to  those  of  general  paralysis  are  met  with  in  lead 
poisoning.  Many  years  ago,  Tancquerel  noticed  a  peculiar  embarrassment 
of  speech,  but  it  was  left  for   Delasiuive  to  demonstrate  its  relation  to 


57©        DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

saturnine  poisoning,  and  for  Parelle  to  describe  the  group  of  symptoms. 
Saturnine  pseudo-general  paralysis  is  a  disease  which  affects  males,  females, 
being  exempt.  The  most  susceptible  age  is  from  40  to  50.  It  de- 
velops suddenly,  being  usually  ushered  in  by  delirium  or  an  epileptiform 
seizure.  Once  the  illness  is  fully  developed,  there  are  depression  of  spirits 
amounting  to  melancholia,  insomnia,  loss  of  memory,  and  muscular  tremor, 
affecting  principally  the  lips  and  tongue  and  causing  embarrassment  of 
speech.  The  patient  resembles  a  general  paralytic,  and  yet  the  illness  may 
decline,  speech  and  intelligence  may  return,  and  the  individual  ultimately 
recover. 

Cord. — Since  muscular  inco-ordination  sometimes  occurs  m  plumbism, 
it  raises  the  cpiestion,  is  there  a  saturnine  pseudo-tabes  ?  Saturnine  tabes  is 
mentioned  by  G-owers;  it  has  been  observed  in  America  by  Putnam,  and  in 
France  by  Teissier  and  Raymond.  I  have  also  met  with  it.  The  pheno- 
mena are  exhibited  mostly  by  males.  Like  the  classic  form  of  tabes,  the 
inco-ordination  is  aggravated  by  closure  of  j;he  eyes.  There  may  be 
diplopia,  loss  of  the  muscular  sense,  incontinence  of  urine,  and,  as  in 
Gowers'  case,  loss  of  the  knee-jerk,  without  any  affection  of  sensibility,  and 
without  the  patient  ever  having  had  colic  Since  patients  thus  afflicted 
usually  improve  rapidly  under  treatment,  this  circumstance  has  suggested 
that  we  are  dealing  with  only  a  functional  derangement  of  the  nervous 
system ;  but  in  a  fatal  case,  described  by  Morris  of  Charlestown,  there  was 
degeneration  of  the  postero-lateral  columns  of  the  spinal  cord.  In  addition 
to  the  above,  I  have  met  with  saturnine  ataxia  in  young  male  lead  workers, 
where,  besides  muscular  inco-ordination  and  diplopia,  there  were  nys- 
tagmus and  exaggerated  knee-jerks,  all  of  which  rapidly  disappeared 
under  treatment. 

Lead  poisoning  may  cause  insanity.  After  working  in  a  white-lead 
factory  for  a  few  months,  a  woman  may  become  suddenly  insensible,  and 
pass  into  a  state  of  coma  which  lasts  for  a  few  days,  its  continuance  being 
occasionally  interrupted  by  an  epileptiform  seizure.  On  regaining  con- 
sciousness, there  may  be  complaint  of  colic  or  of  headache,  double  "  wrist- 
drop "  may  be  noticed,  and  the  presence  of  albumin  in  the  urine  confirmed. 
Without  further  warning,  symptoms  of  acute  mania  arise,  and  on  their 
subsidence  the  patient  is  for  a  time  gloomy  and  despondent.  There  may  be 
no  fresh  development,  except  complaint  of  constant  headache — pains  of  a 
neuralgic  character —  there  being  several  tender  spots  detected  on  pressing 
the  nerves  as  they  escape  from  the  cranial  foramina,  and  then  quite 
unexpectedly  there  is  a  recurrence  of  mania,  the  temperature  suddenly 
rises,  it  may  be,  to  106°,  when  the  patient  dies. 

Peripheral  nerves.— After  working  for  years  in  a  lead  factory,  and 
having  experienced  only  recurrent  attacks  of  mild  abdominal  pain  which 
has  yielded  to  aperients,  an  individual  gradually  or  suddenly  loses  the  power 
in  his  hands — he  cannot  hold  things  as  he  used  to ;  his  hands  fall  powerless 
by  his  side,  owing  to  paralysis  of  the  extensor  muscles  of  the  wrists  and 
fingers.  This  "  wrist-drop  "  is  usually  double,  but  one  hand  may  be  more  - 
affected  than  the  other.  Bilateral  distribution  of  the  paralysis  is  charac-  '. 
teristic  of  metallic  poisoning,  particularly  of  plumbism.  Once  wrist-drop 
develops,  the  loss  of  power  is  followed  by  muscular  atrophy,  which  rapidly 
progresses.  The  lower  part  of  the  forearm  becomes  flattened.  The 
hands  lie  flaccid,  and  are  flail-like  in  their  movement;  the  interosseous 
grooves  deepen,  and  the  thenar  and  hypothenar  eminences  become  flat. 
When  the  patient   attempts   to  extend   his  fingers,  considerable   tremor 


LEAD  POISONING.  571 

of  the  hands  and  forearms  is  induced,  with  synergetic  movement  of  the 
flexor  muscles.  The  flexors  of  the  fingers,  while  weakened,  are  not 
paralysed.  The  supinator  longus  generally  escapes,  and  thus  a  certain 
amount  of  movement  at  the  wrist  is  still  possible.  Occasionally  the 
paralysis  involves  the  muscles  of  the  upper  arm,  and  in  this  form  the 
supinator  longus  may  be  affected.  The  deltoid,  biceps,  brachialis  anticus, 
and  supinator  longus  muscles  constitute  what  is  known  as  the  Duchenne- 
Erb  group,  and  when  these  are  paralysed  it  usually  indicates  rather  a 
severe  type  of  lead  poisoning.  Paralysis  of  this  group  of  muscles  generally 
follows  where  loss  of  power  has  previously  been  noticed  in  the  extensors 
of  the  forearm,  but  it  may  arise  independently.  The  deltoid  is  the  first 
to  suffer,  and  yet,  though  paralysed,  it  is  still  responsive  to  electrical 
stimulation.  The  muscles  of  the  trunk  and  limbs  may  be  also  involved, 
so  that,  as  the  patient  is  unable  to  turn  in  bed,  he  lies  completely  helpless. 
Pain  is  commensurate  in  its  distribution  with  the  loss  of  power,  and  as  the 
muscular  atrophy  makes  rapid  strides,  the  symptoms  are  not  unlike  those 
met  with  in  multiple  neuritis,  except  that  in  many  cases  the  knee-jerks 
are  exaggerated.  Paralysis  may  creep  onwards  until  it  involves  the 
intercostal  muscles  and  the  diaphragm,  so  that  the  patient  is  unable  to 
breathe  and  swallow.  In  this  type  of  lead  poisoning,  death  comes  from 
respiratory  paralysis.  The  voluntary  muscles  have  no  sooner  lost  their 
power  than  they  begin  to  atrophy.  They  exhibit  at  an  early  date,  when 
tested  electrically,  the  "reaction  of  degeneration";  that  is  to  say,  the  muscles 
fail  to  respond  to  faradic  stimulation,  but  contract  to  the  slowly  interrupted 
current. 

In  severe  cases  of  lead  paralysis  affecting  the  forearm,  a  few  of  the 
muscles  of  the  leg  may  be  also  involved,  constituting  the  peroneal  type  of 
the  disease,  the  interesting  point  being  that,  while  the  long  extensor  of  the 
toes  and  the  peronei  muscles  are  affected,  the  tibialis  anticus  (like  the 
supinator  longus  in  the  forearm),  although  supplied  by  the  same  nerve, 
namely,  the  external  popliteal,  escapes.  Before  this  form  of  paralysis 
develops,  there  is  usually  considerable  pain  complained  of  in  the  muscles  of 
the  leg,  the  skin  over  which  may  be  either  hypersesthetic  or  analgesic. 

There  is  a  form  of  lead  poisoning  in  which  the  small  muscles  of  the 
hand,  e.g.  the  interossei  and  those  of  the  thenar  and  hypothenar  promin- 
ences, become  affected, in  which  atrophy  is  not  only  well  marked,  but  seems 
rather  to  keep  pace  with  the  paralysis  than  to  follow  it,  producing  a  loss 
of  power  and  creating  a  deformity  closely  resembling  that  observed  in  pro- 
gressive muscular  atrophy.  It  is  spoken  of  as  the  Aran-Duchenne  type  of 
lead  paralysis,  and  is  said  to  depend  upon  degeneration  of  the  multipolar  cells 
situated  in  the  anterior  horns  of  the  grey  matter  of  the  spinal  cord,  or  upon 
a  gradual  wasting  of  nerve  fibres  and  muscles.  It  resembles  progressive 
muscular  atrophy  in  so  far  as  there  is  a  diminution  of  irritability  to  both 
forms  of  electricity  present  from  the  first,  and  which  gradually  increases, 
there  never  having  been  a  period  of  lost  faradic  and  preserved  voltaic 
excitability.  This  form  of  paralysis  is  extremely  slow  in  disappearing, 
and  complete  recovery  is  but  seldom.  One  of  the  best  illustrations  of 
this  form  of  paralysis  I  have  seen  was  in  a  plumber  in  whom  only  the 
small  muscles  of  the  hands  were  affected.  The  extensors  of  the  wrists, 
although  weakened,  were  not  paralysed.  The  appearance  of  the  hands 
exactly  resembled  that  observed  in  progressive  muscular  atrophy.  There 
was  no  loss  of  sensation.  I  have  observed  the  same  form  of  paralysis  in  the 
file-cutters  at  Painfull.     Those  muscles  are  worst  which,  as  Mobius  showed, 


si 2      Diseases  caused  by  chemical  substances. 

are  preponderatingly  used  in  particular  occupations.  The  plumber  just 
alluded  to  showed  another  interesting  fact,  namely,  the  greater  ease  with 
which  extension  of  the  wrists  could  be  accomplished  when  the  hand  was 
flexed,  also  the  fingers  flexed  upon  the  palm. 

The  paralytic  phenomena  of  double  wrist-drop  are  usually  slow  in 
disappearing,  even  under  treatment,  and  at  the  best  recovery  is  often 
incomplete.  Sensation  over  the  affected  muscles  is  generally  normal,  but 
occasionally  the  skin  is  analgesic,  the  prick  of  a  pin  not  being  felt.  This 
loss  of  sensation  is  frequently  observed  on  the  back  of  the  forearm.  "When 
the  skin  is  pricked,  blood  is  drawn,  a  circumstance  which  shows  that  the 
condition  is  not  one  of  hysterical  anaesthesia.  As  a  rule,  lead  paralysis 
develops  without  fever,  but  Bury,  quoting  Meignen,  alludes  to  a  general- 
ised form  of  paralysis,  occurring  with  pyrexia,  and  attended  by  symptoms 
such  as  at  first  suggested  typhoid  fever  or  subacute  spinal  paralysis. 

Eye. — As  stated  higher  up,  blindness  may  be  a  sequel  of  saturnine 
epilepsy,  but  it  may  arise  apart  from  it.  Three  forms  of  loss  of  sight  are 
met  with  in  plumbism.  In  one,  the  blindness,  which  has  rather  suddenly 
developed,  accompanies  headache.  Complete  or  incomplete,  this  form  is 
always  transient,  and  is  evidently  due  to  a  toxsemic  condition  of  the  central 
or  deeper  parts  of  the  brain  concerned  in  vision,  or  upon  an  anaesthetic 
state  of  the  retina,  for,  on  ophthalmoscopic  examination,  the  disc  and  retina 
are  found  to  be  normal.  Besides,  the  loss  of  sight  is  intermittent ;  vision 
may  at  any  time  return.  In  other  patients  the  loss  of  sight  is  absolute 
and  enduring.  There  may  have  been  colic  and  severe  headache  protracted 
over  a  period  of  days,  or  there  may  have  been  encejDhalopathy,  antecedent 
to  the  loss  of  vision.  The  patient  is  perhaps  young,  and  otherwise  healthy, 
and  the  urine  is  free  from  the  presence  of  albumin.  On  ophthalmoscopic 
examination,  the  discs  are  observed  to  be  swollen,  and  to  have  ill-defined 
and  irregular  borders ;  there  is  distinct  hyperemia  with  mottling,  or  the 
arterioles  are  small  and  obscured,  the  venules  being  distended.  In  addition, 
small  haemorrhages  may  be  observed  close  to  the  border  of  the  disc  or 
in  the  retina.  Subsequently  the  disc  atrophies,  and  becomes  extremely 
pale.  The  sight  is  sometimes  partially  restored  —  usually  it  remains 
permanently  lost.  This  is  the  form  of  neuro-retinitis  met  with  in  acute 
plumbism.  It  differs  from  that  subsequently  to  be  mentioned,  and 
which  occurs  in  chronic  forms,  accompanied  by  kidney  disease  and 
albuminuria. 

Bell  Taylor  mentions  a  case  of  saturnine  amblyopia,  limited  to  one 
eye,  occurring  in  a  young  woman  who  took  diachylon,  10  grs.  nightly  for 
three  weeks,  to  induce  abortion.  There  was  white  atrophy  of  the  left 
optic  disc,  and  marked  central  scotoma  in  both  eyes  (amblyopia  without 
tissue  change).  The  right  eye  recovered  perfectly  under  treatment.  It  is 
interesting  to  note  that,  while  the  diachylon  caused  blindness  in  one  eye, 
there  were  never  any  signs  of  plumbism,  such  as  colic,  blue  line  on  the 
gums,  nor  paralysis.  Diplopia  and  nystagmus  are  occasionally  observed 
in  lead  poisoning,  also  loss  of  colour  perception,  particularly  for  yellow  and 
blue. 

Parotid  gland. — Attention  has  been  drawn  by  Comby  of  the  Sick 
Children's  Hospital,  Paris,  to  a  form  of  toxic  parotiditis  occurring  in  lead 
workers.  Usually  the  glands  on  either  side  of  and  behind  the  jaw  are  swollen 
and  painless.  The  patient  looks  as  if  he  had  mumps.  The  disease  occurs  at 
any  age,  but  there  has  generally  been  a  history  of  colic  and  albuminuria,  and 
occasionally  of  painful  enlargement  of  the  testicle.     Thieleman  in  his  thesis 


LEAD  POISONING.  573 

upon  this  subject  reports  thirty  cases  of  saturnine  parotiditis.  In  some  of 
his  patients  mastication  was  uncomfortable,  and  the  gland  was  painful  to 
the  touch.  He  believes  that  the  parotid  enlargement  is  due  to  elimination 
of  lead  by  the  saliva.  That  lead  is  eliminated  by  the  saliva  has  for  long 
been  known.  Pouchet  found  it  in  the  saliva  of  lead  patients  as  long  as 
three  months  after  the  individual  had  ceased  working  in  the  factory. 
Spillman  injected  pilocarpine  into  a  patient,  suffering  from  saturnine  colic, 
and  within  four  minutes  he  obtained  315  grms.  of  saliva  in  which  he 
found  3  mgrms.  of  lead.  Enlargement  of  the  parotid  gland  has  also  been 
induced  in  saturnine  patients  suffering  from  colic,  by  the  administra- 
tion of  potassium  iodide.  Although  lead  of  itself  may  give  rise  to  a  form 
of  parotiditis,  it  is  more  than  likely  that  in  its  causation  infection  of  the 
gland  plays  a  part  equally  important  to  saturnine  intoxication. 

Antrum. — Maxillary  sinusitis  has  been  found  by  H.  L.  Wagner 
to  be  due  to  chronic  lead  poisoning.  The  symptoms  were  excruciating 
right  supra-orbital  pain  and  hyperosmia,  whereby  strong  odours  excited 
pain.  There  was  hypertrophy  of  the  lower  and  middle  turbinated  bodies 
on  right  side  of  nose,  a  sero-purulent  discharge  rich  in  micro-oiganisms, 
with  crusting  at  the  entrance  of  the  hiatus  semilunaris,  and  pain  on 
pressure  over  the  region  of  the  first  right  molar  tooth.  There  was  no 
blue  line  on  the  gums ;  the  man  was  a  coachman,  a&t.  32.  Diagnosing 
disease  of  the  antrum,  the  hard  palate  was  drilled  and  the  cavity  packed 
with  borated  gauze.  No  relief  followed.  No  lead  was  found  at  this  stage 
in  the  urine,  but  as  the  fresh  scrapings  of  the  hypertrophied  tissue  of  the 
antrum  gave,  with  sodium  sulphide,  a  lead  reaction,  patient  was  placed 
upon  iodide  of  potassium.  In  a  few  days  all  pain  had  disappeared  and 
the  discharge  lessened,  and  shortly  afterwards  the  patient  was  well.  The 
urine,  hitherto  free,  now  exhibited  a  trace  of  lead.  Wagner  regarded  the 
diseased  condition  of  the  antrum,  including  the  neuritis  of  adjacent  nerves, 
as  due  to  the  deposit  of  lead,  probably  in  the  form  of  albuminate. 

Testicle. — Orchitis  is  said  to  be  caused  by  lead.  I  have  only  met 
with  it  onco  in  a  lead  worker,  and  where  all  other  causes  could  be 
excluded. 

Gout. — Plumbism  and  gout  are  correlated.  The  association  of  the 
two  diseases  is  not  so  close,  however,  as  some  maintain.  In  the  north 
of  England  and  in  Scotland,  gout  is  not  a  common  disease,  and  as  a 
symptom  of  lead  poisoning  it  hardly  ever  occurs.  In  London  and  the 
south  it  is  just  the  reverse.  Climate,  the  drinking  habits,  and  the 
nature  of  the  food  of  the  people,  may  have  much  to  do  in  explaining 
this  difference.  Whisky  is  the  drink  of  the  North  and  beer  of  the  South, 
and  it  is  admitted  that  beer  of  itself  tends  to  develop  uratosis.  Erom  my 
experience  of  gout  and  lead  poisoning,  I  am  of  opinion  that  in  nearly  every 
instance  in  which  gout  has  arisen  in  an  individual  suffering  from  lead  poison- 
ing, it  has  been  due  to  a  hereditary  predisposition  to  gout,  and  in  this  opinion 
I  am  supported  by  Ebstein,  who,  in  describing  the  ailments  of  the  lead 
workers  on  the  Harz  Mountains,  has  come  to  a  similar  conclusion,  namely, 
the  comparative  absence  of  gout  in  individuals  who  are  free  from  the 
hereditary  taint  of  the  disease ;  also  by  Eoberts,  who  states  that  both  in 
the  gouty  diathesis  and  in  plumbism  the  same  tendency  is  present,  namely, 
the  deposition  of  crystalline  urates  in  the  tissues  of  the  body.  This  vice  in 
a  lead  poisoned  individual,  or,  as  Roberts  calls  it,  saturnine  uratosis,  is 
exaggerated,  if  such  a  person  is  hereditarily  predisposed  to  gout.  In 
plumbism,  the  elimination  both  of  urea  and  uric  acid  is  defective.     Uric 


574        DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

acid  is  apparently  retained  in  the  system,  owing  probably  to  lead 
circulating  in  the  blood,  reducing  its  alkalinity,  and  thereby  rendering  the 
uric  acid  insoluble. 

Garrod  found  uric  acid  in  the  blood  of  seven  out  of  nine  persons 
suffering  from  plumbism,  without  any  gouty  symptoms.  This  circum- 
stance clearly  shows  that  lead  has  a  tendency  to  cause  accumulation  of 
uric  acid  in  the  blood.  Of  this  we  have  further  confirmation  in  the  fact 
that,  when  acetate  of  lead  is  administered,  it  is  followed  by  a  diminished 
elimination  of  uric  acid  in-  the  urine.  It  is  therefore  astonishing  that  in 
Newcastle-upon-Tyne,  where  so  much  lead  poisoning  prevails,  there  should 
be  such  a  marked  absence  of  gouty  complications.  So  rare,  in  fact,  is  the 
association,  that  five  or  six  years  will  pass  without  a  case  being  admitted 
into  the  infirmary ;  probably  not  once  in  400  patients.  In  nearly  every 
instance  where  I  have  met  with  gout  and  plumbism,  the  patient  has  been 
a  male,  usually  a  house  painter,  and  his  father  and  grandfather  have 
followed  the  same  occupation.  It  is  not  therefore  a  question  simply  of 
lead  poisoning  in  the  individual  immediately  causing  gout,  but  of  a  con- 
stitutional peculiarity  developed  under  the  influence  of  lead,  hereditarily 
transmitted,  and  out  of  which,  during  plumbism,  the  gouty  state  may  be 
evolved.  Luff,  in  his  Goulstonian  Lectures,  has  carefully  dealt  with  this 
subject.  He  considers  that  the  gouty  paroxysm  in  saturnine  poisoning 
depends  rather  upon  functional  imperfection  of  the  renal  epithelia.  It  is 
not  necessary,  he  says,  that  the  kidneys  should  be  absolutely  diseased,  but 
should  act  imperfectly  so  that  uric  acid  cannot  be  eliminated.  While  lead 
poisoning  predisposes  to  gout,  it  is  more  than  likely  that  gout  also  pre- 
disposes to  plumbism. 

That  nitrogenous  metabolism  in  lead  poisoning  is  diminished  and 
deranged,  there  is  no  doubt.  My  own  observations  support  those  of 
Surmont  and  Brunelle  and  Gaucher.  The  urea  is  usually  diminished, 
but  the  uric  acid  varies,  being  sometimes  increased,  sometimes  diminished. 
It  is  by  deranging  nutrition  that  lead  poisoning  causes  gout.  To  induce 
this  illness,  the  system  must  be  gradually  and  slowly  brought  under  the 
influence  of  the  metallic  poison.  That  is  one  reason  why  house  painters 
suffer  most  from  gout,  while  white-lead  workers  escape.  All  my  patients 
who  have  had  saturnine  gout  were  house  painters,  and  in  them  there  was 
not  only  the  history  of  a  long  exposure  to  lead,  but  also  one  of  a  hereditary 
influence.  The  disease  as  observed  in  plumbism  differs  in  no  way  from 
ordinary  gout,  unless  in  its  greater  tendency  to  be  associated  with  inter- 
stitial nephritis,  a  tendency  to  appear  at  an  earlier  age,  usually  before 
35  ;  that  it  develops  in  people  not  in  good  health,  as  does  ordinary  gout,  but 
in  those  who  are  anaemic,  reduced  in  health,  and  frequently  albuminuric ; 
that  it  tends  to  invade  other  joints  than  the  big  toe,  and  that  several 
attacks  may  be  experienced  within  a  few  years. 

Rare  as  saturnine  gout  is  in  the  north  of  England  and  Scotland,  it  is 
quite  as  uncommon  in  Prance  and  Germany.  Ebstein  did  not  observe 
any  very  close  relationship  between  plumbism  and  gout,  nor  did  Jacob 
(Lauthenthal)  find  gout  frequent  amongst  the  miners  of  the  Oberharz. 
Opposed  to  this,  however,  we  have  the  testimony  of  Luethje,  that  of 
6000  workmen  800  were  employed  in  that  particular  part  of  the  factory- 
where  silver  is  extracted  from  the  lead  ore.  These  were  therefore  exposed 
to  plumbic  emanations,  the  proportion  of  men  employed  being  thirteen 
miners  to  two  silver  extractors.  During  eight  years  he  found  that  217 
miners  suffered  from  gout,  also  103  of  the  men  engaged  in  the  desilvering 


LEAD  POISONING.  575 

processes ;  that  is,  one  case  of  gout  in  twenty-four  miners  for  one  in  eight 
silver  workers.  It  would  be  interesting  to  know  the  drinking  habits  of 
the  two  classes  of  workmen,  and  to  what  extent,  if  any,  their  food  differed. 
Diagnosis. — As  a  rule,  the  diagnosis  of  acute  lead  poisoning  is  easy. 
The  history  of  the  case,  the  sudden  development  and  severity  of  the  colic, 
the  extreme  restlessness  of  the  patient,  previous  complaint  of  metallic 
taste  in  the  mouth,  and  the  presence  of  a  blue  line  on  the  gums,  all  testify 
to  lead  being  the  cause  of  the  illness.  The  difficulty  of  diagnosis  arises 
in  cases  where  there  is  no  blue  line  on  the  gums,  no  history  of  the  individual 
having  come  into  contact  with  lead,  and  where  the  health  has  been  simply 
gradually  undermined.  A  slowly  developing  cachexia  with  a  sense  of 
malaise,  recurrent  abdominal  pain,  a  history  of  monorrhagia,  or  repeated 
miscarriages  if  a  female,  great  debility,  mental  depression,  and  constipation, 
accompanied  by  a  disagreeable  taste  in  the  mouth,  occurring  in  an  in- 
dividual whose  organs  are  otherwise  healthy,  should  oblige  us  to  examine 
the  urine  for  traces  of  lead,  and  particularly  so  if,  in  addition  to  the 
above,  there  is  an  ill-defined  or  limited  paralysis.  The  presence  of  lead 
in  the  urine  is  not  absolute  proof  of  chronic  lead  poisoning.  Como  and 
Worcester  examined  the  urine  of  150  persons  living  in  Boston,  and  found 
lead  in  25  per  cent.  In  none  of'  these  people  were  there  signs  of  plumbism. 
Bilateral  paralysis  is  extremely  suggestive  of  plumbism.  It  might  be 
mistaken  for  alcoholic  neuritis,  but  although  pain  in  the  muscles  is  also 
complained  of  in  lead  poisoning,  there  is  less  tenderness  in  them  when 
grasped  by  the  hand  than  in  early  alcoholic  paralysis ;  in  plumbism,  too, 
the  loss  of  power  affects  rather  the  muscles  of  the  upper  than  •  the 
lower  extremities.  This  circumstance  tends  to  differentiate  it  also  from 
arsenical  paralysis,  where  the  muscles  that  are  affected  are  those  that  flex 
the  ankle  and  extend  the  toes.  Paralysis  from  pressure  upon  the  musculo- 
spinal nerve  is  unilateral,  that  from  plumbism  is  bilateral.  Apart  from  the 
history  of  the  case,  it  is  difficult  to  diagnose  the  convulsive  seizures  of 
lead  encephalopathy  from  ordinary  epilepsy  or  uraemia,  but  the  presence 
of  a  blue  line  on  the  gums  and  albumin  in  the  urine  would  be  a  guide. 

Chemical  tests  for  lead. — Since  lead  is  a  subtle  poison  and  is 
eliminated  by  the  kidneys,  the  detection  of  the  metal  in  the  urine  of  a 
patient  would,  other  symptoms  being  present,  pretty  conclusively  point 
to  the  illness  being  lead  poisoning.  The  examination  is  made  as  follows : 
Evaporate  50  c.c.  or  2  oz.  of  urine  to  dryness;  ignite  the  residue,  extract 
the  lead  from  this  by  means  of  sulphuretted  hydrogen  or  ammonium 
sulphide.  The  objections  to  this  procedure  are  its  tediousness,  and  the 
necessity  for  the  preliminary  destruction  of  organic  matter.  In  Abram 
and  Marsden's  method,  a  strip  of  magnesium  is  placed  in  the  fluid  to  be 
examined.  Ammonium  oxalate,  in  the  proportion  of  1  grm.  to  150  c.c, 
is  added.  If  lead  is  present,  it  is  deposited  on  the  magnesium.  A  deposit 
is  seen  within  half  an  hour,  but 'it  may  require  a  longer  exposure.  The 
slip  is  then  washed  with  distilled  water,  and  dried.  To  confirm  the  test — 
(1)  Warm  the  slip  with  a  crystal  of  iodine  upon  it — a  yellow  colour  proves 
the  existence  of  lead ;  (2)  dissolve  the  deposit  in  nitric  acid,  and  apply  the 
usual  tests  for  lead.  This  is  an  extremely  delicate  test ;  it  is  capable  of 
detecting  1  part  of  lead  in  50,000,  whether  the  metal  is  dissolved  in  water 
or  is  contained  in  an  organic  liquid  like  urine.  It  is  difficult  to  say  for 
how  long  lead  will  be  eliminated  by  the  urine,  but  in  a  case  of  acute  lead 
poisoning  Zinn  found  the  metal  twenty-five  days  afterwards.  Lead  also 
leaves  the  body  by  the  fseces. 


576         DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

Prognosis. — In  the  minor  forms  of  plumbism  the  prognosis  is  favour- 
able. The  mortality  of  lead  colic  is  less  than  2  per  cent.  Recovery 
from  lead  paralysis  is  variable,  both  as  regards  rapidity  and  completeness. 
Once  an  individual  has  suffered,  he  should  be  removed  from  all  possible 
chances  of  contact  with  the  poison.  In  patients  who  are  cachectic,  who 
have  had  repeated  attacks  of  colic,  and  whose  urine  is  albuminous,  the 
prognosis  is  unfavourable.  Under  all  circumstances,  lead  encephalopathy 
is  serious,  not  only  at  the  time,  but  on  account  of  such  sequeke  as 
blindness  and  melancholia. 

Treatment. — The  treatment  of  plumbism  is  preventive  and  curative. 
If  the  illness  depends  upon  the  use  of  contaminated  drinking-water,  care 
should  be  taken  to  remove  from  it  all  organic  impurities,  such  as  nitrates 
and  nitrites,  to  neutralise  acidity  if  present,  get  rid  of  carbonic  acid  by 
exposure,  to  harden  the  water  (if  soft)  by  adding  limestone  or  by 
passing  it  through  fine  sand,  to  substitute  glass-lined  or  iron  pipes  for 
those  made  of  lead,  to  avoid  the  storage  of  drinking-water  in  lead  cis- 
terns, and  to  have  water  for  all  purposes  of  cooking  and  drinking  carried 
into  the  houses  direct  from  the  main  by  iron  pipes,  and  that,  where 
water  has  lain  in  the  pipes  of  a  house  overnight,  to  allow  it  to  run  to 
waste  in  the  morning  for  a  few  minutes  before  using  it.  Thresh  speaks 
favourably  of  galvanised  iron  pipes,  since  even  if  the  zinc  is  acted  upon 
by  the  water,  zinc  is  not,  like  lead,  a  cumulative  poison.  For  lead  workers 
in  white-lead  factories,  regulations  are  now  in  force  which  will  tend  to 
minimise  but  not  remove  the  risk  to  health.  By  attention  to  cleanli- 
ness and  the  use  of  sulphur  baths,  plumbism  may  be  largely  avoided. 
The  curative  part  of  the  treatment  divides  itself  into  that  for  (1)  colic 
and  its  accompaniments,  (2)  paralysis,  (3)  encephalopathy,  and  (4)  the 
deteriorated  health  of  chronic  plumbism. 

For  constipation  and  mild  colic,  a  gentle  aperient,  e.g.  Epsom  salts  or 
castor-oil,  may  be  sufficient,  but  the  pain  may  be  so  great  that,  in  addition  to 
the  above,  opiates  or  belladonna  may  be  necessary,  or  a  hypodermic  injec- 
tion of  morphine.  Should  constipation,  colic,  and  vomiting  continue,  enema ta 
may  be  called  for,  and  the  administration  of  effervescing  mixtures  along 
with  the  application  of  belladonna  fomentations  to  the  abdomen.  If  these 
measures  fail,  colic  can  generally  be  relieved  by  a  warm  bath.  A  mixture  of 
potassium  iodide,  magnesium  sulphate,  and  tincture  of  belladonna  is  usually 
sufficient  both  as  an  aperient  and  calmative.  Combemale  finds  large  doses 
of  olive  oil  very  useful  in  relieving  colic ;  and,  should  the  oil  be  vomited, 
then  3  grs.  of  menthol  administered  before  the  next  dose  of  oil  will  allay 
the  sickness.  Experience  has  led  me  to  regard  monosulphite  of  soda  in  5  to 
10  gr.  doses,  or  more,  thrice  daily,  as  a  good  calmative  for  colic  and  as  an 
eliminator  of  lead.  Potassium  iodide  is  generally  regarded  as  the  best 
eliminant  of  lead.  It  must  be  used  with  caution,  however,  for  there  are 
cases  on  record  which  support  the  theory,  propounded  by  Melsens,  that 
in  a  quiescent  case  of  plumbism  alarming  symptoms  may  suddenly  develop, 
under  the  administration  of  potassium  iodide,  owing  to  the  drug  rendering 
soluble,  and  therefore  absorbable  into  the  circulation,  lead  which  had  been 
deposited  in  the  tissues,  and  was  inert. 

For  saturnine  paralysis  the  application  of  electricity  and  the  employ- 
ment of  massage,  combined  with  the  internal  administration  of  potassium 
iodide  and  nux  vomica,  or  the  subcutaneous  injection  of  liq.  strychninae,  are 
useful.  The  application  of  electricity,  while  the  patient  is  in  an  acidulated 
bath,  as  recommended  by  Semmola  and  alluded  to  by  Yeo,  is  said  to  have 


LEAD  POISONING.  577 

been  followed,  by  a  rapid  elimination  of  lead  from  the  system,  as  evidenced 
by  the  blue  line  quickly  disappearing  from  the  gums,  and  the  increasing 
quantities  of  lead  found  in  the  urine.  The  question  of  the  elimination  of 
lead  by  electricity  from  the  system  of  a  lead-poisoned  individual  has  lately 
been  revived.  It  was  an  old  belief  that  lead  and  mercury  could  be  ex- 
tracted from  patients'  bodies  by  electricity,  but  there  is  nothing  to  confirm 
this  statement.  Lewis  Jones  has  employed  alternating  currents  with 
great  success.  Electrolysis  can  play  no  part  in  the  result,  for  this  is 
rather  the  property  of  the  direct  current.  Electricity,  by  stimulating- 
nerve  and  muscle,  and  by  improving  the  circulation,  favours  elimination 
by  natural  methods.  Jones  recommends  an  arm  bath  of  stoneware  filled 
with  warm  water.  Into  this  the  forearms  and  hands  of  the  patient  are 
inserted,  and  an  electrical  current  passed  from  one  end  of  the  bath  to  the 
other.  It  is  here  the  electrodes  are  placed.  The  alternating  current 
obtainable  from  the  electric  light  main  of  100  volts  is  reduced  by  a 
transformer  to  12,  14,  or  16  volts,  .to  suit  each  individual  case.  Experi- 
ence shows  that,  although  paralysed  muscles  do  not  contract  to  alternating 
currents,  they  are  still  favourably  influenced  by  them  and  recovery 
hastened.  For  patients  belonging  to  the  wealthier  classes,  and  whose 
circumstances  allow  of  them  visiting  Continental  spas,  the  waters  of 
Carlsbad  and  of  Brides-les-Bains  are  highly  recommended. 

For  the  convulsive  seizures  of  lead  encephalopathy  the  inhalation  of 
nitrite  of  amyl  often  cuts  short  the  attack,  and,  where  there  is  suppression 
of  urine,  relief  will  follow  the  hypodermic  injection  of  pilocarpine.  In  some 
cases  venesection  might  become  necessary,  followed  by  saline  transfusion. 

As  regards  those  cases  of  chronic  plumbism  with  cachexia  and  signs  of 
impaired  general  health,  attention  to  the  diet,  which  should  be  largely  milk, 
regulation  of  the  bowels,  prevention  of  cold,  abstinence  from  alcohol,  and 
the  internal  administration  of  syr.  ferri  iodidi,  or  tabloids  of  bone  marrow, 
may  do  much  to  prolong  life.  At  this  stage,  however,  treatment  must  be 
more  or  less  symptomatic. 

Lead  Poisoning  in  Children. 

Symptoms. — Allusion  has  been  made  to  contaminated  drinking  water 
as  one  of  the  commonest  causes  of  accidental  plumbism.  In  the  Colonies, 
where  water  is  sometimes  scarce,  and  has  to  be  stored  for  lengthened 
periods  in  galvanised-iron  tanks,  Jefferis  Turner  and  Lockhart  Gibson  have 
succeeded  in  tracing  obscure  forms  of  nervous  disease  in  children  to  this 
source.  In  the  manufacture  of  galvanised-iron  tanks,  it  has  frequently 
been  found  that  the  molten  zinc  into  which  the  iron  tanks  have  been 
dipped  in  order  to  become  galvanized,  contains  lead.  Some  of  this  becomes 
dissolved  in  the  water  which  lies  undisturbed  in  the  tank  during  long 
spells  of  dry  weather.  The  government  analyst  of  Queensland  found  lead 
in  sufficient  quantity  to  be  harmful,  in  the  water  which  had  lain  for  some 
time  in  galvanised-iron  tanks.  In  Brisbane,  children  suffered  from  head- 
ache and  vomiting,  followed  by  paralysis  of  the  ocular  muscles,  and  by 
blindness,  symptoms  which  at  first  suggested  meningitis  rather  than 
poisoning.  Jefferis  Turner  and  Lockhart  Gibson,  after  carefully  unravel- 
ling all  the  facts,  succeeded  in  differentiating  the  cases,  and  placing 
them  in  their  proper  category.  In  adults,  plumbic  paralysis  as  a  rule 
appears  first  in  the  extensors  of  the  wrists  and  fingers,  but  in  children  of 
tender  years  "  foot  drop  "  is  usually  one  of  the  earliest  nervous  manifesta- 
vol.  1. — 37 


578        DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

tions  of  lead  poisoning,  the  muscles  affected  being  the  tibialis  anticus  and 
the  extensor  longus  digitorum  ;  sometimes,  too,  the  peronei.  Later  on,  in 
advanced  cases  there  may  be  weakness  and  altered  electrical  reaction  of 
the  calf  muscles,  spasm  of  these  muscles,  and  persistent  talipes  equinus. 
Should  the  arms  become  affected,  the  extensors  of  the  fingers  are  the  first 
to  become  paralysed,  those  of  the  wrist  only  when  the  illness  is  more 
pronounced.  The  short  muscles  that  form  the  ball  of  the  thumb  may  also 
become  paretic  and  wasted,  the  adductor  pollicis,  however,  being  less  liable 
to  be  thus  affected  than  the  abductor  opponens  and  flexor  brevis.  The 
interossei  do  not  exhibit  in  children  the  same  tendency  to  become  paralysed 
as  in  adults.  Turner  saw  two  patients  in  whom  there  was  paralysis  of  the 
diaphragm.  In  the  paper  from  which  I  have  quoted,  Turner  lays  consider- 
able stress  upon  the  fact  of  paralysis  from  lead  poisoning  in  children 
occurring  first  in  the  feet  and  legs,  as  opposed  to  the  wrists,  and  in  this 
he  is  supported  by  the  experience  of  J.  J.  Putnam,  who  found  in  every 
instance  the  legs  affected  as  much  if.  not  more  than  the  arms,  and  that 
the  paralysis  had  always  appeared  first  in  the  lower  extremities,  just 
as  in  arsenical  and  alcoholic  poisoning.  As  in  adults,  so  in  children,  the 
development  of  paralysis  is  often  preceded  by  "  bilious  attacks,"  recurring 
every  few  months,  during  which  there  is  acute  abdominal  pain,  the  bowels 
being  usually,  but  not  invariably,  constipated,  for  occasionally  there  is 
diarrhoea.  A  blue  line  may  be  present  in  the  gums,  but  this  as  a  physical 
sign  is  oftener  absent  in  children  than  in  adults,  owing  probably  to  the 
smaller  amount  of  nitrogenous  food  they  consume,  and  the  fact  that  the 
teeth  in  young  children  seldom  collect  tartar.  Once  the  colic  is  recurrent, 
it  may  be  followed  by  pains  in  the  muscles  of  the  legs,  and  by  paralysis 
and  convulsions.  If  a  patient  has  had  convulsions,  it  is  observed,  on  his 
regaining  consciousness,  that  there  is  paralysis  of  some  of  the  ocular 
muscles,  usually  the  external  rectus,  that  the  face  is  slightly  paralysed, 
that  the  head  is  retracted,  and  that  the  child  is  blirid.  1On  ophthalmo- 
scopic examination,  there  is  found  double  optic  neuritis,  the  discs  are 
swollen,  there  is  exudation  into  and  around  them,  the  veins  are  tortuous 
and  distended,  and  small  haemorrhages  here  and  there  are  observed  in  the 
retinae.  By  degrees  these  signs  subside,  and  the  discs  are  noticed  to  be  pale 
and  passing  into  a  condition  of  post-neuritic  atrophy.  In  the  lead  poison- 
ing of  children,  one  of  the  distinguishing  features  is,  that  while  there  is  a 
marked  tendency  for  optic  neuritis  to  develop,  it  is  much  more  frequently 
associated  with  oculo-motor  paralysis  than  in  adults.  Occasionally  the 
course  of  the  illness  is  broken  by  febrile  attacks,  which  last  for  a  few  days, 
and  the  cause  of  which  is  rather  obscure.  The  face  begins  to  wear  a 
pained  expression,  the  skin  becomes  pale  and  swarthy,  and  the  urine,  while 
it  may  or  may  not  show  a  distinct  trace  of  albumin,  almost  invariably,  on 
careful  chemical  analysis,  is  found  to  contain  a  minute  quantity  of  lead. 

It  is  difficult  to  say  to  what  extent  children,  compared  to  adults, 
suffer  from  plumbism  in  endemic  lead  poisoning.  John  Brown  of  Bacup 
had  the  opportunity  of  investigating  303  cases  of  lead  poisoning  which 
occurred  in  one  year  in  his  district,  and  he  gives  us  the  following : — 


-Under  1  year  .  =   5  cases. 

5  years  and  under  10  years  =  18     ,, 
10         „  ,,      15     „     =20     ,, 


15  years  and  under  25  years  =   68  cases. 
25         „  „      50     „     =144     „ 

50         ,,  upwards      .      =48     ,, 


Brown  found  in  this  epidemic  that  lead  poisoning  occurred  less  frequently 
in  children,  a  circumstance  probably  due  to  their  greater  eliminating 
powers.     In  Queensland,  on  the  other  hand,   lead  poisoning  appears  to 


ARSENICAL  POISONING. 


579 


have  played  sad  havoc  with  children.  Taking  the  Brisbane  Children's 
Hospital  alone,  seventy-six  cases  of  plumbism  were  admitted  in  six  years, 
and  of  these  seven  died.  In  all  probability  the  cases  in  private  practice 
were  just  as  numerous.  No  age  of  childhood  seemed  to  be  exempt 
after  the  first  year,  but  the  ages  of  5,  6,  and  7  seemed  to  be  the  most 
vulnerable,  for  these  years  furnished  71  per  cent,  of  the  total  cases.  It  is 
interesting,  too,  to  note  that  even  at  this  early  age  females  showed  a  greater 
susceptibility  to  lead  poisoning  than  males :  72  per  cent,  of  the  patients 
were  girls.  Although  all  the  children  in  the  family  were  drinking  the 
same  water,  the  poison  affected  only  one  or  two  of  the  most  susceptible. 
Turner,  as  the  result  of  his  experience,  believes  that  children  are  more 
susceptible  to  plumbism  than  adults,  and  he  lends  considerable  weight  to 
the  opinion  I  have  always  expressed,  namely,  the  greater  susceptibility  of 
the  female  sex.     Children  of  a  gouty  father  are  specially  prone  to  suffer. 

Diagnosis. — A  history  of  recurrent  headache,  bilious  vomiting,  and 
abdominal  pain,  presence  of  a  blue  line  on  the  gums  (oftener  absent,  how- 
ever, than  present),  paralysis  of  various  muscles,  the  loss  of  power,  appear- 
ing first  in  the  leg  and  foot,  and  subsequently  involving  the  fingers  and 
wrists,  preceded  by  tenderness,  and  followed  by  wasting,  are  of  themselves 
extremely  suggestive  of  lead  poisoning.  Add  to  these  symptoms — convul- 
sions, followed  by  oculo-motor  paralysis,  usually  of  the  external  rectus, 
facial  paralysis,  retracted  head,  stiffness  of  the  neck,  and  changes  in  the 
optic  disc ;  and  while  there  is  in  these  symptoms  much  to  suggest  a  basal 
meningitis,  the  presence  of  lead  in  the  drinking  water,  the  detection  of 
a  trace  of  lead  in  the  urine,  the  fact  that  muscular  paralysis  and  disc 
changes  are  frequently  simultaneous,  that  the  disc  changes  are  sometimes 
unilateral  and  on  the  side  opposite  to  the  paralysed  external  rectus,  also 
that  in  cases  where  there  has  only  been  optic  neuritis  the  patients  have 
recovered,  and  we  have  a  congeries  of  signs  and  symptoms  pointing  pretty 
conclusively  to  lead  poisoning. 

Treatment. — The  treatment  of  lead  poisoning  in  children  is  practic- 
ally the  same  as  for  adults.  If  due  to  drinking  water,  remove  the  patient 
from  his  home,  and  discontinue  the  use  of  the  contaminated  water ;  allow 
him  no  sweetmeats  that  are  artificially  coloured  ;  promote  elimination  by 
gentle  action  upon  the  bowels  by  saline  aperients,  by  diaphoretics,  such  as 
the  subcutaneous  injection  of  pilocarpine,  followed  up  by  the  internal 
administration  of  potassium  iodide,  carefully  the  while  watching  its  effects. 


AESENICAL  POISONING. 


Poisoning  by  an  overdose  of  arsenic,  or  arsenious  acid  and  its  com- 
pounds, administered  accidentally,  suicidally,  or  with  criminal  intention. 
Arsenic  causes  few  deaths  either  accidentally  or  suicidally,  but  criminally 
the  number  is  large.  During  five  years  ending  1890,  seventeen  fatal 
cases  of  arsenical  poisoning  occurred,  of  which  twelve  were  males  and 
five  females,  whilst  during  the  quinquennium  ending  1895,  arsenic  caused 
sixty-four  deaths.     By  the  term  white  arsenic  we  mean  arsenious  acid. 

History  and  etiology. — The  poisonous  properties  of  arsenic  have 
long  been  known.  Its  comparative  tastelessness  is  one  reason  why  it  has 
been  so  frequently  resorted  to  for  criminal  purposes.     Metallic  arsenic  is 


580        DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

harmless.  It  is  only  when  it  is  brought  into  contact  with  the  juices  of  the 
animal  body,  or  is  volatilised,  that  it  assumes  highly  poisonous  properties. 
Arsenical  compounds  cause  poisoning,  whether  they  enter  the  system  by 
inhalation,  are  swallowed  with  the  food,  or  are  applied  externally  to  the  skin. 
It  is  owing  to  the  escharotic  properties  of  white  arsenic  that  it  was  formerly 
used  in  the  surgical  treatment  of  cancer.  As  the  active  ingredient  of  a 
paste  applied  to  cancer,  it  is  known  to  have  caused  death.  Men  who  are 
employed  in  smelting  zinc  frequently  suffer  from  symptoms  of  arsenical 
poisoning,  owing  to  the  presence  of  arsenic  in  spelter.  Cobalt  miners  are 
similarly  affected ;  so  also  are  workmen  who  are  engaged  in  the  manufac- 
ture of  emerald-green.  Arsenic  is  largely  employed  as  a  medicine  in  the 
form  of  Fowler's  solution,  or  liquor  arsenicalis,  which  is  a  1  per  cent, 
solution,  with  an  alkaline  reaction,  composed  of  arsenite  and  carbonate 
of  potassium  and  coloured  by  sandal  wood.  In  small  doses,  Fowler's 
solution  is  a  valuable  remedy,  but  its  administration  requires  care. 
Of  late  it  has  been  given  rather  freely  in  the  treatment  of  chorea, 
and  has  caused  bronzing  of  the  skin,  gastro-intestinal  irritation,  and 
paralysis,  which  have  gradually  disappeared  on  discontinuing  the  medicine. 
A  few  years  ago  arsenic  was  frequently  present  as  a  pigment  in  wall 
papers.  People  occupying  rooms  thus  lined  frequently  suffered  from  great 
depression  of  spirits,  nausea,  vomiting,  irregular  stools,  headache,  dry  throat, 
laryngeal  and  bronchial  catarrh,  reddened  eyelids,  symptoms  suggestive  of 
a  severe  cold  in  the  head,  whilst  others  suffered  from  gastritis.  The 
detection  of  arsenite  of  copper  in  wall  paper  and  the  experiments  per- 
formed by  Kramer  in  1852,  with  the  view  of  determining  how  far  volatile 
arsenical  compounds  could  be  liberated  under  these  circumstances,  con- 
firmed the  suspicion  of  the  symptoms  being  due  to  arsenical  poisoning. 
Previous  to  this,  Basedow  had  in  1846  drawn  attention  to  poisoning 
arising  from  wall-paper,  and  in  1848  he  succeeded  in  getting  the 
Prussian  Government  to  make  penal  the  addition  of  arsenic  to  wall 
paper.  It  is  now  generally  admitted  that  illness  may  be  caused 
by  the  inhalation  of  arsenical  dust,  arseniuretted  hydrogen,  or  arsine, 
arising  from  the  action  of  arsenious  acid  upon  organic  matter.  Gosio 
and  Sanger  have  shown  that  volatile  arsenical  compounds  are  formed 
by  the  operation  of  certain  moulds  upon  organic  matter  containing  arsenic, 
and  that  in  the  growth  of  these  moulds  an  intense  garlicky  odour, 
characteristic  of  arsenic,  is  evolved.  Saccardo  found  in  decaying  paper, 
one  mould,  the  Penicillium  brevicaule,  which  is  so  sensitive  to  the 
presence  of  arsenic,  that  Gosio  utilises  it  as  one  means  for  detecting 
arsenic  in  toxicological  preparations.  Other  micro-organisms  may  be 
similarly  endowed,  but  there  are  four  arsenio-bacteria,  about  whose 
operation  there  is  no  doubt,  and  these  are  the  Penicillium,  brevicaule,  Mucor 
muceclo,  Aspergillum  glaucum,,  and  Aspergillum  virens.  Experiments  with 
these  moulds  show  that  a  gaseous  or  volatile  compound  is  generated  from 
decaying  arsenical  matter. 

Although  arsenic  is  poisonous  to  all  forms  of  animal  life,  it  can  yet 
be  taken  for  a  lengthened  period,  and  with  considerable  impunity,  provided 
small  doses  are  commenced  with.  There  is  some  truth  in  the  arsenic 
eating  powers  of  the  Styrian  peasantry,  and  their  immunity  from  the 
disastrous  consequences  usually  observed  in  cases  where  the  drug  has  been 
administered  rather  freely.  Anything  above  two  grains  of  arsenious  acid 
must  be  regarded  as  a  dangerous  dose. 

Morbid  anatomy. — In  acute  cases,  pathological  changes  are  observed 


ARSENICAL  POISONING.  581 

in  the  stomach  and  intestines.  The  mucous  membrane  is  swollen  and 
congested,  and  is  the  seat  of  numerous  small  ecchymoses  or  emphysematous 
bullae.  It  may  be  covered  with  a  diphtheritic  exudation.  So  persistent  is 
the  inflammatory  redness  of  the  stomach  and  intestines,  that  a  few  months 
after  a  person  has  died  from  arsenical  poisoning,  the  coloration  may  still  be 
recognised,  owing  to  the  preservative  powers  of  the  drug.  At  times  the 
redness  extends  the  whole  length  of  the  alimentary  canal,  and  resembles 
that  observed  in  cholera,  a  likeness  which  microscopical  examination  may 
strengthen,  owing  to  the  micro-organisms  described  by  Klebs  as  character- 
istic of  cholera  being  found  in  the  epithelial  flakes.  Peyer's  patches  and 
the  solitary  glands  may  be  swollen.  Arsenic  has  such  a  selective  influence 
for  the  lining  membrane  of  the  stomach,  that,  quite  irrespective  of  the 
channel  by  which  it  gains  entrance  into  the  system,  it  is  eliminated  by 
the  mucous  membrane  of  this  viscus.  Thus  is  explained  the  anomalous 
behaviour  of  the  poison,  that  in  order  to  prove  fatal  a  larger  quantity  has 
to  be  injected  into  a  vein  than  when  taken  by  the  mouth.  From  the 
blood  it  is  eliminated  by  the  gastric  mucous  membrane,  and  in  its  passage 
outwards  it  acts  as  an  irritant,  causing  inflammatory  redness.  The  cells 
of  the  liver  and  kidneys,  and  the  fibres  of  voluntary  muscle,  are  the  seat  of 
fatty  degeneration.  Salkowski  states  that  the  glycogenic  function  of  the 
liver  is  destroyed,  but  in  animals,  the  subjects  of  experimental  arsenical 
poisoning,  I  have  found  that  the  liver  always  contained  plenty  of  glycogen. 
Of  the  nature  of  the  combinations  formed  by  arsenic  in  the  body  it  is  diffi- 
cult to  speak  with  certainty.  Liebig  thought  that  it  formed  with  albumin 
a  stable  non-putrefactive  compound,  while  Binz  and  Schulz  maintain  that 
in  the  animal  organism  arsenious  acid  is  converted  by  oxidation  into 
arsenic  acid,  and  that  this  latter  is  reduced  to  arsenious.  Arsenic 
would  thus  be  simply  an  oxygen  carrier  to  the  tissues,  hence  its  stimulat- 
ing: influence  in  nutrition,  where  under  its  administration  the  cells  of 
the  liver  and  kidneys  proliferate,  and  the  bones  of  young  animals  become 
overgrown. 

Paralysis  may  follow  the  administration  of  small  doses  of  arsenic  con- 
tinued for  a  period,  or  after  swallowing  one  large  dose.  Meirowitz  reports 
recovery  from  the  acute  intestinal  symptoms,  in  a  man  who  had  inad- 
vertently swallowed  77  grs.  of  arsenious  acid.  Subsequently,  he  developed 
an  ataxic  gait,  with  loss  of  knee-jerks ;  his  legs  became  painful,  and  his 
feet  swollen.  Symptoms  of  multiple  neuritis,  sensory  and  motor,  became 
well  marked,  and  yet  the  patient  recovered.  Sensory  disturbance  is 
more  profound;  in  this  circumstance  and  in  the  fact  that  the  loss  of 
power  is  usually  below  the  knee,  lies  the  distinction  between  arsenical 
and  lead  paralysis.  In  a  doubtful  case  the  urine  should  be  tested  for 
arsenic. 

The  use  of  the  term,  arsenical  multiple  neuritis,  suggests  that  the 
paralysis  depends  upon  a  peripheral  lesion,  but  proof  of  this  is  wanting. 
Paralysis  consequent  upon  metallic  poisoning  has  hitherto  been  regarded 
as  due  to  a  peripheral  neuritis,  but  pathologists  have  recently  rather  looked 
to  certain  changes  primarily  occurring  in  the  central  nervous  system  as  the 
explanation  of  the  phenomena.  In  his  experimental  arsenical  poisoning  of 
dogs,  Popoff  found  the  spinal  cord  inflamed  in  the  early  stages ;  in  the 
more  chronic  cases,  that  the  small  arteries  of  the  cord  were  thickened,  that 
the  protoplasm  of  the  large  multipolar  cells  became  opaque  and  granular, 
their  nucleus  indistinct,  and  that  the  cells  subsequently  became  vacuolated. 
Myelitis  and  changes  in  the  ganglion  cells,  similar  to  those  just  described, 


582        DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

have  been  observed  by  other  writers.  It  is  to  be  noted  that  during  the  time 
such  a  profound  structural  alteration  was  taking  place  in  the  cord,  there  was 
no  tenderness  experienced  along  the  course  of  the  nerves.  In  other  cases 
where  the  symptoms  suggested  a  central  lesion,  no  pathological  changes 
have  been  found;  the  alterations  in  the  cells  must  have  been  purely 
dynamic,  and  not  such  as  to  be  revealed  microscopically.  Occasionally,  the 
peripheral  nerves  are  the  seat  of  neuritis,  so  that  we  must  regard  the 
nervous  lesions  of  arsenical  poisoning  as  both  central  and  peripheral,  the 
localisation  of  which  is  apparently  determined  by  individual  circumstances 
and  predisposition.  The  protean  nature  of  the  symptoms  observed  in 
chronic  arsenical  poisoning  obliges  us  to  take  this  view.  Baymond  reports 
the  case  of  a  girl,  7  years  of  age,  who,  after  taking  arsenic  for  chorea, 
developed  paralysis  of  the  legs,  followed  by  incontinence  of  urine  and 
faeces,  difficulty  of  swallowing,  and  an  eschar  on  the  back.  In  such  a  case 
there  is  much  to  suggest  a  central  lesion. 

Symptoms. — Arsenical  poisoning  is  acute  or  chronic,  according  to 
the  close  and  the  length  of  time  the  drug  has  been  taken.  A  fairly  large 
dose  causes  a  burning  pain  in  the  gullet  and  stomach,  which  gradually 
spreads  all  over  the  abdomen ;  it  creates  a  sense  of  constriction  in  the 
throat,  and  a  metallic  taste  in  the  mouth.  These  are  followed  shortly  after- 
wards by  vomiting  and  purging,  attended  by  considerable  pain.  The  stools 
are  bloody  or  contain  large  quantities  of  bile  and  flaky  mucus,  and  are  not 
unlike  those  observed  in  cholera.  Arterial  tension  is  lowered,  and  there  is 
considerable  collapse.  The  pulse  becomes  feeble  and  irregular ;  the  respira- 
tion is  laboured  and  embarrassed,  on  account  of  abdominal  tenderness; 
thirst  is  excessive,  and  the  urine  is  suppressed ;  the  face  becomes  pinched, 
pale,  and  cyanosed,  and  the  expression  anxious.  Cramp-like  pains  keep 
recurring  and  make  the  patient  restless ;  he  becomes  convulsed,  paralysed, 
or  comatose,  and  in  this  condition  he  dies  in  from  five  to  twenty  hours  after 
having  taken  a  few  grains  (3-5)  of  arsenic.  So  rapid  is  the  death,  and  so 
close  the  resemblance  of  the  symptoms  to  those  exhibited  in  Asiatic  cholera, 
that  were  this  disease  epidemic  at  the  time,  and  nothing  ascertainable  in  the 
history  of  the  case  or  surroundings  to  excite  suspicion,  a  mistake  might 
readily  and  pardonably  be  made  in  the  diagnosis. 

In  subacute  arsenical  poisoning,  as  the  dose  has  been  smaller,  the 
symptoms  are  correspondingly  less  severe  and  remittent.  Vomiting  and 
purging  may  cease,  only  in  a  few  days  to  return  again.  Abdominal  pain 
may  be  complained  of  on  pressure ;  the  patient  is  thirsty,  and  has  painful 
swallowing;  the  urine  is  scanty,  and  frequently  it  is  albuminous;  the 
heart's  sounds  are  feeble  and  irregular ;  face  cyanosed  or  pale :  skin 
clammy  and  exhaling  a  peculiar  odour  of  arseniuretted  hydrogen.  There 
are  cramps  in  the  legs  and  convulsions.  The  intellect,  as  a  rule,  is  clear 
to  the  last  in  slow  arsenical  poisoning.  The  symptoms  are  remittent,  the 
patient  rallies  for  a  time,  but  the  improvement  is  not  maintained. 

A  single  large  dose  of  arsenic  may  be  followed  by  death,  or  a  prolonged 
illness  supervenes,  which  may  ultimately  prove  fatal.  Although  the 
symptoms  at  first  are  connected  with  the  alimentary  canal,  it  is  ultimately 
on  the  side  of  the  nervous  system  that  they  are  most  observed.  Motion 
and  sensation  are  affected.  In  nearly  one-half  of  the  patients  all  the 
extremities  are  affected ;  one-fourth  are  paraplegic,  while  in  the  remainder 
there  is  a  limited  paralysis  or  a  hemiplegia.  It  is  characteristic  of  arsenical 
paralysis  that  the  loss  of  power  is  principally  observed  in  the  muscles 
below  the  knee,  that  the  muscles  rapidly  atrophy,  and   are   extremely 


ARSENICAL  POISOXIXG.  583 

sensitive  to  pressure,  also  that  they  early  exhibit  the  reaction  of  degenera- 
tion, namely,  an  absence  of  response  to  the  faradic  current  whilst  acting 
to  the  galvanic.  The  paralytic  phenomena  of  arsenical  subacute  polio- 
myelitis are  accompanied  by  pain  and  sensory  derangement,  and  exhibit 
a  tendency  to  recover. 

In  consequence  of  the  administration  of  small  doses  of  arsenic  for  a 
lengthened  period,  the  health  of  the  individual  is  slowly  deteriorated, 
and  other  diseases  are  simulated.  The  appetite  is  lost,  the  individual 
emaciates,  becomes  increasingly  feeble,  and  suffers  from  depression  of 
spirits,  irritability  of  temper,  and  sleeplessness ;  the  skin  becomes  darker, 
urine  scanty,  the  extremities  numb  and  paralysed.  It  is  in  such  cases 
that  a  chemical  examination  of  the  urine  for  arsenic  may  at  once  clinch 
the  diagnosis. 

Diagnosis. — The  diagnosis  of  the  minor  forms  of  arsenical  poisoning 
is  not  always  easy,  but,  given  the  group  of  symptoms  previously  described, 
or,  if  a  child,  the  history  of  chorea  followed  by  paralysis  and  bronzing  of 
the  skin  during  treatment  by  Fowler's  solution,  then  with  such  facts  before 
us  we  should  examine  the  urine  for  traces  of  arsenic  by  such  a  method, 
e.g.  as  the  following : — Eeduce  12  to  16  oz.  of  urine,  by  gentle  evapora- 
tion, to  one-fourth  of  its  bulk ;  add  one-sixth  to  one-fifth  of  pure  hvdro- 
chloric  acid;  insert  a  bright  piece  of  copper  foil,  and  boil  for  at  least 
fifteen  minutes  when,  if  arsenic  is  present,  the  copper  will  exhibit  a  greyish 
stain.  Further  on  we  allude  to  the  differential  points  in  the  diagnosis  of 
lead,  alcoholic,  and  arsenical  paralysis.  In  acute  poisoning  by  white  arsenic, 
microscopical  examination  of  the  vomit  may  reveal  the  presence  of  small 
white  particles,  which,  when  washed,  dissolved  in  boiling  water,  and 
allowed  to  cool,  crystallise  out  as  octahedra  of  arsenious  acid.  These, 
when  heated  with  charcoal  and  soda  in  a  blow-pipe,  evolve  the  garlicky 
odour  of  arsenic. 

In  any  case  where  paralysis  follows  acute  arsenical  poisoning,  it  is 
important  to  remember  that  the  loss  of  power  may  not  appear  until  lono- 
after  the  time  the  poison  was  taken,  and  when  memory  of  the  fact  no  longer 
occupies  a  prominent  place  in  the  history  that  is  given  of  the  illness.  On 
inquiry,  however,  it  will  generally  be  elicited  that  there  were  gastro-in- 
testinal  troubles,  such  as  vomiting  and  diarrhoea,  which  gradually  subsided ; 
that  these  were  followed  by  a  condition  in  which  the  limbs  were  at  first 
enfeebled  and  painful,  or  the  seat  of  tingling  and  numbness,  and  that 
gradually  the  muscular  weakness  passed  into  paralysis,  which  either 
affected  the  four  extremities  simultaneously,  or,  as  is  more  usual,  the  lees. 
"When  the  paralysis  affects  the  limbs,  it  commences  at  the  periphery  and 
creeps  upwards  towards  the  trunk,  the  loss  of  power  diminishing  from 
the  periphery  to  the  centre.  The  extensor  muscles  are  usually  more  affected 
than  the  flexors,  and  those  on  the  anterior  aspect  of  the  thigh  than  the  pos- 
terior. In  four  or  five  weeks  the  paralysis  reaches  its  height,  when  for 
a  period  it  remains  stationary,  during  which  the  tendon  reflexes  are  found  to 
be  abolished,  and  there  are  observed  signs  of  the  reaction  of  degeneration, 
diffused  muscular  atrophy,  and  loss  of  surface  sensibility.  The  muscles  are 
painful  on  pressure.  Occasionally  anaesthesia  is  replaced  by  hyperesthesia. 
Pronounced  as  is  the  paralysis,  both  it  and  the  muscular  atrophy  are 
curable.  "Within  a  few  weeks  they  gradually  disappear,  improvement 
taking  place  first  at  the  proximal  end  of  the  limbs  and  then  extending 
towards  the  periphery.  It  is  during  this  period  of  recession  that 
d'Erlicki  and  Piybalkin  observed  contracted  tendons  in  the  limbs,  especi- 


584        DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

ally  of  fingers  and  toes,  and  that  the  skin  became  glossy  and  the  seat  of 
erythematous  eruptions. 

Almost  similar  sequelae  follow  subacute  arsenical  poisoning.  There  is 
paralysis,  loss  of  surface  sensation,  pains  in  the  calves,  muscular  inco- 
ordination, abolished  reflexes,  dilated  pupils,  and  inability  to  close  the 
eyelids.  The  initial  gastro-enteritis  may  not  have  been  so  severe  as  that 
already  described,  but  it  is  more  persistent,  and  accompanied  by  febrile  rises 
of  temperature,  conditions  which  ere  this  have  suggested  the  probability  of 
such  a  case  being  one  of  typhoid  fever.  When  paralysis  develops  in  this 
form,  it  has  a  preference  for  certain  groups  of  muscles,  e.g.  the  common 
extensors  of  the  toes,  the  tibialis  anticus,  the  proper  extensor  of  the  big 
toe,  the  peronei,  and  later  on  the  vasti  interni.  It  respects  the  gemini  and 
soleus.  If,  however,  paralysis  has  slowly  developed,  it  may  not  remain  cir- 
cumscribed, but  extend  to  all  the  extremities  and  involve  even  the  muscles 
of  the  trunk. 

A  case  reported  by  Mott  is  a  good  illustration  of  arsenical  paralysis, 
commencing  in  one  limb  and  extending.  The  man  was  employed  in  a 
chemical  factory  to  wash  the  indiarubber  clothing  worn  by  men  who 
make  "  sheep  dip,"  which  is  known  to  contain  large  quantities  of  arsenic. 
Unfortunately  this  individual  was  not  supplied  with  indiarubber  gloves, 
and  as  the  result  of  the  repeated  immersion  of  his  right  hand  in  what 
became  practically  an  alkaline  solution  of  arsenic,  he  began  to  suffer,  six 
weeks  afterwards,  from  numbness  and  tingling  in  the  fingers  of  the  right 
hand,  with  progressive  loss  of  power  in  the  hand.  There  was  no  tender- 
ness on  pressure  over  the  ulnar  nerve,  but  considerable  loss  of  sensation  to 
pressure,  heat,  and  cold.  There  was  diminished  reaction  to  the  faradic 
current  in  the  muscles  of  both  arms  and  hands ;  no  reaction  of  degenera- 
tion with  the  galvanic  current.  Twelve  months  afterwards  there  was  still 
the  same  loss  of  power  in  the  right  hand ;  fingers  and  thumb  were  fixed 
and  semiflexed.  There  was  paresis  in  both  legs,  and  a  tottering  spastic 
gait,  exaggerated  knee-jerks,  ankle-clonus,  skin  of  right  hand  was  smooth 
and  glossy,  pupils  and  discs  were  normal.  The  sensation  of  the  right  hand 
had  improved,  but  not  its  power  of  movement ;  the  left  hand  was  feeble, 
and  there  was  general  muscular  weakness.  The  paralysis  of  the  right 
hand,  the  progressive  enfeeblement  of  the  muscles  of  the  left  hand  and 
legs,  the  tottering  gait  with  exaggerated  knee-jerks  and  ankle-clonus, 
indicate  a  degeneration  of  the  cortical  pyramidal  neurons,  progressive  in 
character.  This  cerebral  degeneration  may  or  may  not  have  been  due 
directly  to  arsenic,  but  the  right  hand  and  arm  were  evidently  the  result 
of  a  neuritis,  as  indicated  by  the  glossy  skin.  Probably  the  first  effects  of 
the  poison  were  upon  the  endings  of  the  peripheral  nerves  of  the  right 
hand.     Arsenic,  though  searched  for,  was  never  found  in  the  urine. 

In  industrial  poisoning  by  arsenic,  e.g.  in  emerald-green  makers,  paint 
mixers,  wall-paper  and  artificial-flower  makers,  etc.,  paralysis  may  occur. 
Putnam  has  reported  twenty-five  cases  of  arsenical  poisoning  due  to  sleep- 
ing in  rooms  the  wall  paper  of  which  contained  arsenic.  Most  of  the 
patients  developed  a  polyneuritis.  Imbert-Courbeyre  quotes  the  case  of 
a  young  unmarried  woman,  who,  finding  herself  pregnant,  took  large  doses 
of  arsenic  with  the  view  of  inducing  miscarriage.  In  course  of  time 
she  was  confined  of  a  still-born  child,  and  shortly  afterwards  she  herself 
developed  paralysis,  affecting  motion  and  sensation  of  the  legs. 

In  addition  to  paralysis,  muscular  atrophy,  and  altered  sensibility, 
some  writers  mention  ataxia,  tremor,  and  epileptic  convulsions,  as  sequelae 


ARSENICAL  POISONING.  585 

of  arsenical  poisoning.  These  are  also  met  with  in  chronic  alcoholism. 
Alcoholic  paralysis  rarely  shows  itself  after  a  debauch  unless  there  has 
previously  been  long-continued  drinking.  In  such  cases  we  have  rather 
delirium  than  acute  gastro-intestinal  troubles;  the  latter  are  more  char- 
acteristic of  arsenic.  As  differential  symptoms,  we  might  say  that  sensory 
troubles,  anaesthesia  and  pain,  are,  if  anything,  more  pronounced  in  arsenical 
than  alcoholic  poisoning,  while  loss  of  memory  and  intellectual  aberration 
are  more  suggestive  of  alcoholic  than  arsenical  poisoning.  Alcoholic 
paralysis  is  never  followed  by  desquamation ;  arsenical  may  be.  Both 
poisons  may  cause  deformities.  In  arsenical  paralysis  the  small  muscles  of 
the  hands  and  feet,  the  interossei  and  the  thenar,  are  affected,  so  that  the 
patient  cannot  separate  or  approximate  his  fingers  and  thumb ;  whereas  in 
alcoholic  the  movements  first  affected  are  those  which  concern  the  ankles 
and  wrists,  for  the  paralysis  affects  the  extensors  and  flexors  of  the  feet 
and  hands.  Deformities  occur  in  arsenical  paralysis,  and  are  met  with  on  the 
fingers  and  toes,  so  that  the  different  phalanges  become  immobile  in  flexion 
and  extension,  and  the  feet  become  arched.  In  alcoholic  subjects,  when  the 
tendons  become  contracted,  it  is  principally  the  muscles  of  the  forearm  and 
leg  that  are  affected,  and  as  a  consequence  we  have  fixation  of  the  hands  or 
feet  in  flexion  or  extension.  In  arsenical  paralysis  the  deformities  occur  at 
the  joints  of  the  fingers  and  toes ;  in  alcoholic,  they  are  situated  on  the 
wrists  and  ankles. 

Prognosis. — The  minor  forms  of  poisoning  usually  recover.  In  acute 
cases  in  which  the  symptoms  are  severe,  or  where  the  paralysis  involves 
the  respiratory  muscles,  the  prognosis  is  unfavourable. 

Treatment. — So  long  as  there  is  arsenic  in  the  stomach,  the  antidote 
is  freshly  prepared  ferric  hydrate,  made  by  adding  liq.  amnion,  fort,  to  liq. 
or  tinct.  ferri  perchlor.,  taking  care  to  add  the  ammonia  gradually,  so  as 
not  to  have  it  in  excess.  Another  method  is  by  precipitating  tinct.  ferri 
perchlor.  by  sodse  bicarb.,  and  filtering  through  a  handkerchief.  Ferric 
hydrate  acts  by  converting  the  soluble  arsenic  in  the  stomach  into  the 
insoluble  arseniate  of  iron.  The  stomach  should  be  washed  out  if  the 
antidote  is  not  at  hand.  Once  the  arsenic  is  absorbed,  neither  ferric 
hydrate  nor  lavage  is  of  any  service.  Treatment  thereafter  must  be  purely 
symptomatic.  Copious  draughts  of  water  favour  the  elimination  by  the 
kidneys.  Mucilaginous  drinks,  composed  of  white  of  egg,  barley  water, 
olive  oil,  or  lime  water  are  recommended,  also  castor-oil.  When  the  cramp- 
like  pains  are  severe,  morphine  hypodermically  or  by  the  mouth  may  be  called 
for,  also  hot  applications  externally.  The  chronic  forms  of  arsenical  poison- 
ing are  best  treated  by  iodide  of  potassium,  with  or  without  sulphate  of 
magnesia,  or  some  other  gentle  aperient.  In  cases  of  paralysis,  so  soon  as 
all  sensory  disturbance  has  subsided,  electricity  and  massage  should  be 
resorted  to  ;  and  in  those  patients  whose  ill-health  is  traced  to  sleeping  in  a 
bedroom  the  wall-paper  of  which  contains  arsenic,  the  individual  should 
be  at  once  removed  from  that  room,  sent  away  for  change  of  air  to  another 
locality,  and  meanwhile  the  walls  of  the  room  stripped  of  the  paper. 


586         DISEASES  CA  USED  BY  CHEMICAL  SUBSTANCES. 


PHOSPHOEUS  POISOXIXG. 

Etiology. — Poisoning  by  phosphorus  is  acute  or  chronic.  In  the  acute 
form  the  symptoms  are  consequent  upon  swallowing  the  non-nietallic  sub- 
stance known  as  phosphorus,  usually  with  suicidal  intent.  The  symptoms  of 
chronic  poisoning  are  mostly  observed  among  match-makers.  In  England 
phosphorus  poisoning  is  mostly  suicidal.  During  five  years  ending  1890, 
thirty-six  fatal  cases  of  phosphorus  poisoning  occurred,  fourteen  males 
and  twenty-two  females ;  during  the  quinquennium  ending  1895  there 
were  sixty-seven  fatal  cases.  Poisoning  by  phosphorus  is  a  painful  and 
not  always  a  rapid  method  of  self-destruction,  and  yet,  in  spite  of  this  fact, 
which  is  pretty  generally  known,  men  and  women,  but  particularly  women, 
either  through  jealousy,  drink,  ill-usage  by  their  husbands,or  through  poverty, 
heedlessly  resort  to  drinking  a  solution  of  match  heads  in  water  as  a  means 
of  terminating  their  life.  The  common  vermin  pastes,  since  they  contain 
phosphorus  in  a  finely  divided  form,  are  also  resorted  to  for  this  purpose. 
Of  the  two.  varieties  met  with  in  commerce,  it  is  the  yellow  or  white,  as 
distinguished  from  the  red  or  amorphous  phosphorus,  that  is  so  poisonous. 
Obtained  from  the  bones  of  animals  by  operating  upon  them  with  sulphuric 
acid,  and  subsequently  reducing  the  resulting  superphosphate  by  means  of 
charcoal  in  retorts,  at  a  high  temperature,  phosphorus  exists  as  a  soft,  solid, 
waxy,  transparent  substance,  which  emits  a  strong  garlicky  odour,  is  rapidly 
oxidised,  and  is  so  inflammable  that  it  must  be  kept  under  water.  Yellow 
phosphorus  is  in  this  country  mostly  used  in  the  manufacture  of  ordinary 
matches.  The  red  or  amorphous  form  not  only  does  not  catch  fire  at  the 
ordinary  temperature  like  the  yellow,  but  is  practically  non-poisonous,  and 
is  used  for  making  "  safety  "  matches.  This  form,  which  was  invented  by 
Schrotter,  is  obtained  by  heating  the  common  phosphorus  in  closed  iron 
vessels  to  a  very  high  temperature,  whereby  it  is  rendered  colourless,  loses 
its  phosphorescence,  does  not  strike  on  percussion  or  moderate  friction,  and 
as  stated  is  non-poisonous. 

It  is  a  little  more  than  half  a  century  since  the  profession  became 
familiar  with  phosphorus  poisoning.  There  is  an  opinion  that  the  sulphur 
match  tipped  with  phosphorus  originated  in  Stockton-on-Tees,  but  as 
Vienna  became  the  centre  of  the  friction  match  industry,  it  is  to  Austria 
and  certain  parts  of  Germany  that  we  look  for  the  early  reports  of 
poisoning.  Although  matches  began  to  be  made  in  1833,  it  was  not  until 
1845  that  Lorinser  reported  twenty-two  cases  of  poisoning;  from  that 
date  onwards  until  now,  facts  have  been  accumulating  which  point  to 
phosphorus  as  a  substance  extremely  inimical  to  life,  and  its  fumes  as 
capable  of  producing  in  -people  who  are  exposed  to  them  serious  disease  of 
the  bones  of  the  jaw. 

In  nearly  all  the  departments  of  a  lucifer  match  factory  there  are  un- 
pleasant fumes  evolved,  but  some  departments  are  much  more  dangerous  to 
health  than  others.  The  "composition"  used  for  match  heads  consists  of  phos- 
phorus, potassium  chlorate,  glue,  antimony  sulphide,  manganese  peroxide, 
powdered  glass,  and  colouring  matter.  It  is  not  necessary  that  the  paste 
should  contain  more  than  5  per  cent,  of  phosphorus.  It  is  to  the  presence 
of  potassium  chlorate  in  the  match  head  that  when  struck  the  rapid  ignition 
and  the  sharp  explosion  are  due.  The  person  who  stirs  the  "  composition," 
the  people  who  dip  the  matches  into  it,  and  those  who  are  engaged  in  the 
boxing-room,  inhale  more  or  less  of  the  Qbnoxious  fumes ;  hence  these  de- 


PHOSPHORUS  POISONING.  587 

partments  are  all  more  or  less  dangerous.  In  the  manufacture  of  "  safety  " 
matches,  and  many  of  those  that  come  from  Sweden,  there  is  less  risk  to 
health,  owing  to  the  red  or  amorphous  and  not  the  yellow  phosphorus 
being  used ;  whereas  in  France,  particularly  in  Marseilles,  so  distinctly 
recognisable  were  the  effects  of  the  fumes  upon  the  health  and  constitution 
of  the  match-makers,  that  the  term  plbosphorism  was  employed  to  designate 
the  intoxication  that  is  slowly  developed,  and  in  which  cachexia,  a  garlicky 
odour  of  the  breath  and  saliva,  anaemia,  abortion  amongst  women,  a  high 
rate  of  infant  mortality,  albuminuria  and  cystitis  are  the  most  prominent 
symptoms. 

Morbid  anatomy  and  pathology. — Numerous  small  haemorrhages 
may  be  observed  in  the  skin,  on  the  mucous  and  serous  membranes,  and 
between  the  muscles.  The  cadaver  is  generally  bile-stained,  and  there 
arises  from  it  a  strong  odour  of  phosphorus.  The  liver  is  enlarged  and 
fatty,  but  it  may  be  shrunken,  from  disintegration  of  the  hepatic  cells,  if 
the  patient  lived  for  some  time  after  taking  the  poison.  The  spleen  may 
or  may  not  be  enlarged.  Nearly  all  the  internal  organs  will  be  found  to 
have  undergone  fatty  degeneration,  a  condition  which  involves  even  the 
small  blood  vessels.  This  widespread  fatty  degeneration  is  believed  by 
Bauer  and  others  to  depend  upon  chemical  changes  in  the  cellular 
protoplasm,  consequent  upon  inefficient  oxidation,  for  during  life  less  oxygen 
is  found  to  be  absorbed  than  in  health  and  less  carbonic  acid  formed. 
The  haemorrhages  in  the  skin  may  be  consequent  upon  fatty  changes  in 
the  blood  vessels,  or  they  may  come,  as  Thoma  asserts,  from  capillaries, 
whose  walls,  whilst  exhibiting  no  striking  pathological  changes,  are  yet 
more  permeable,  especially  the  intima,  which  under  normal  conditions 
only  allows  the  fluid  part  of  the  blood  to  pass  into  the  tissues,  but  restrains 
the  cellular  elements.  To  the  destruction  of  hepatic  and  red  blood  cells, 
to  imperfectly  formed  biliary  salts,  and  the  resulting  catarrhal  condition 
of  the  lining  membrane  of  the  small  biliary  ducts  consequent  upon 
irritation  by  the  unhealthy  bile,  leading  thereby  to  obstruction  followed  by 
absorption,  must  be  attributed  the  jaundice  in  phosphorus  poisoning.  In 
consequence  of  the  fatty  degeneration  of  the  liver  and  kidneys,  the 
functional  activity  of  these  organs  is  so  impaired  that  they  allow  of  the 
retention  of  animal  poisons  within  the  system,  and  as  a  result  of  this, 
and  the  excess  of  lactic  acid  circulating  in  the  blood,  there  develop 
somnolence  and  coma. 

Phosphorus  is  known  to  exercise  a  stimulating  influence  upon  the 
nutrition  of  bone.  In  chickens  that  had  received  phosphorus  in  their 
food,  the  bones  were  found  to  be  extremely  hard ;  all  spongy  tissue  had 
disappeared,  and  was  replaced  by  dense  bone,  in  which  the  Haversian 
canals  were  obliterated.  Kassowitz  repeating  these  experiments  of  Wegner, 
found  that  such  was  the  fact  up  to  a  certain  point  only,  for  if  he  pushed 
the  administration  of  the  phosphorus  the  medullary  spaces  became  larger, 
and  the  bones  presented  the  appearances  found  in  rickets.  It  is  upon 
work-people  exposed  to  its  malevolent  fumes  that  the  injurious  effects 
of  phosphorus  are  principally  seen,  and  for  a  knowledge  of  which  we 
are  largely  indebted  to  Wegner.  Match-makers  hardly  ever  exhibit  the 
symptoms  of  acute  poisoning,  while,  on  the  other  hand,  people  who  have 
taken  internally  large  doses  of  phosphorus  do  not  suffer  from  the  pain- 
ful affection  of  the  jawbone.  To  this  general  statement  there  are  ex- 
ceptions, as  for  example  the  case  of  a  girl  reported  by  Foumier  and 
Ollivier,  who,  in  addition  to  necrosis  of  the  jaw,  exhibited  symptoms  of 


"588        DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

acute  poisoning  along  with  purpuric  hemorrhages,  and  cerebral  symp- 
toms ending  fatally  in  six  days,  and  in  whose  internal  organs  no  fatty 
degeneration  was  detected.  Wegner  found  that  the  experimental  adminis- 
tration of  the  poison  was  not  followed  by  periosteal  changes,  unless  he 
bared  the  tibiae  and  exposed  the  animals  to  the  fumes  of  phosphorus, 
when  periostitis  followed.  It  is  in  the  inferior  maxillary  bone  of  lucifer 
match-makers  that  the  ravages  of  phosphorus  are  principally  seen,  in  the 
form  of  periostitis,  leading  to  necrosis.  There  is  first  toothache,  which  is 
not  relieved  by  extraction  of  the  tooth,  nor  followed  by  an  early  clos- 
ing of  the  wound,  for  it  continues  to  discharge  a  foul,  offensive  pus,  the 
gums  keep  ulcerating,  and  through  the  opening  are  discharged  pieces  of 
dead  bone.  The  disease  may  limit  itself  or  require  to  be  dealt  with 
surgically,  but  in  some  patients  the  morbid  process  advances,  until  nearly 
the  whole  of  the  jawbone  is  involved,  when  the  constitution  becomes  under- 
mined through  the  progressing  necrosis  and  septic  absorption,  emaciation 
and  hectic  become  well  marked,  and  death  comes  not  seldom  through 
tuberculous  disease.  Among  the  makers  of  the  phosphorus  vermin  pellets, 
which  are  sold  in  Saxony,  Zehnter  found  bronchitis  and  broncho-pneumonia 
not  uncommon  symptoms. 

Industrial  phosphorus  poisoning. — In  match  factories  where 
white  phosphorus  is  used,  it  is  the  mixing,  dipping,  and  boxing  departments 
that  are  the  most  dangerous.  Both  the  mixer  and  the  dipper  run  the  risk 
of  inhaling  the  phosphorus  fumes.  These  fumes  are  composed  of  phos- 
phoric oxide  (P4O10),  phosphorus  oxide  (P406),  and  phosphorus.  The 
girls  who  fill  the  boxes  have  to  handle  the  matches,  and  as  these  frequently 
become  ignited,  dense  clouds  of  an  irritating  smoke  arise,  which  cannot  but 
be  inhaled.  It  is  no  uncommon  thing  to  see  the  hands  of  the  girls  stained 
from  contact  with  the  match  heads ;  they  smell  strongly  of  phosphorus, 
and  if  not  washed  they  are  luminous  in  the  dark.  Thorpe  found  as  much 
as  37  mgrms.  of  phosphorus  in  the  water  in  which  the  workpeople  had 
washed  their  hands.  The  poison  may  thus  gain  an  entrance  into  the 
system,  through  workpeople  eating  with  unwashed  hands,  or  through 
inhaling  the  fumes  of  phosphorus  pentoxide  (P4O10)  during  combustion  of 
the  matches.  But  there  is  another  channel  of  entrance  to  which  we  shall 
allude.  It  is  strange  that  match-makers  should  suffer  from  phosphorism 
and  from  phosphorus  necrosis,  while  the  makers  of  the  white  or  yellow 
phosphorus  very  largely  escape.  Most  of  the  phosphorus  used  in  Europe  is 
made  either  at  Oldbury,  near  Birmingham,  or  at  Lyons,  and  it  will  give  the 
reader  some  idea  of  the  magnitude  of  the  match  industry,  when  I  mention 
that  upwards  of  1200  tons  of  white  phosphorus  are  used  annually  in  the 
manufacture  of  lucifers.  Of  this  amount  60  tons  are  consumed  in  the 
match  works  of  Great  Britain  and  Ireland.  There  has  been  considerable 
discussion,  both  in  the  British  and  foreign  parliaments,  owing  to  the 
amount  of  illness  among  match-makers,  as  to  whether  the  use  of  white 
phosphorus  should  not  be  entirely  prohibited.  In  the  United  Kingdom 
there  are  twenty-four  match  factories  using  the  yellow  phosphorus,  and 
giving  employment  to  4500  people,  of  whom  1908  are  engaged  in  the 
dangerous  processes.  From  1893  until  the  end  of  June  1898  there  have 
been  notified  to  the  Home  Office  thirty-one  cases  of  phosphorus  necrosis, 
and  during  1897  this  caused  two  deaths.  Two  years  ago  the  French 
Government  appointed  a  commission  to  inquire  into  the  subject  of 
phosphorism  among  the  match-makers  of  Pantin-Aubervilliers.  Out  of 
620  men  and  women  employed  in  these  works,  124  were  found  to  have 


PHOSPHORUS  POISONING.  589 

painful  carious  teeth,  and  of  these  people  twenty  had  suffered  from 
necrosis  of  the  jaw  between  1890  and  1897.  At  Grammont,  one  of  the 
principal  seats  of  match-making  in  Belgium,  and  which  contains  six 
factories  giving  employment  to  1100  people,  Brocorens,  between  1860  and 
1895,  met  with  thirty-four  cases  of  phosphorus  necrosis  with  eleven  deaths. 
Kocher,  in  1894,  estimated  the  proportion  of  cases  of  necrosis  in  Switzer- 
land to  be  equal  to  two  to  three  per  cent,  of  the  workers.  Kuiypers  has 
reported  eighteen  cases  of  phosphorus  necrosis  treated  in  Jena  Hospital, 
1890-95.  The  principal  accident  which  befalls  a  match-maker  is  necrosis 
of  the  jawbone.  It  is  believed  that  through  a  penetrating  caries  of  the 
teeth  the  phosphorus  fumes  find  their  way  into*  the  deeper  structures, 
setting  up  a  septic  periostitis,  followed  by  necrosis  of  bone.  It  is  more 
than  likely  that  other  agencies  are  at  work  in  addition  to  the  fumes.  In 
the  discharges  from  the  necrotic  jaws  of  match-makers  I  have  found  such 
putrefactive  micro-organisms  as  staphylococci  and  streptococci,  while 
Stockman  found  tubercle  bacilli,  and  consequently  he  considers  phos- 
phorus necrosis  to  be  very  largely  a  tuberculous  disease  of  the  bone. 
During  twenty-five  years  Brocorens  met  with  thirty  cases  of  spontaneous 
fracture  of  bone  caused  by  muscular  effort,  and  affecting  exclusively  the 
lower  extremities,  in  workmen  who  had  been  employed  as  "dippers." 
More  than  one-half  of  these  men  had  previously  suffered  from  necrosis. 
The  fractures  healed  as  readily  as  in  other  people. 

In  addition  to  necrosis  and  fracture  of  bone,  there  is  another  form  of  phos- 
phorus poisoning  induced,  namely,  phosphorism  characterised  by  cachexia, 
a  peculiar  yellow  tinge  of  the  skin  and  albuminuria.  Good  teeth  in 
match-makers  are  regarded  as  a  protective.  No  person  with  carious  teeth 
ought  to  work  in  the  dangerous  departments  of  a  match  factory.  It  is 
not  always  easy  to  detect  the  early  stages  of  phosphorus  intoxication. 
Albert  Eobin  claims  that  he  has  found  out  a  diagnostic  sign  of  great 
importance.  Normally  the  amount  of  mineral  substances  in  the  urine  is 
one-third  of  the  whole  of  the  solids  (30  in  100).  In  phosphorus-poisoned 
people  he  found  the  ratio  frequently  as  high  as  50  or  even  60  per  cent. 
The  "  co-efficient  of  demineralisation "  is,  according  to  Eobin,  in  match- 
makers almost  double  of  that  in  health.  It  is  to  the  increased  "  co- 
efficient of  demineralisation"  that  Eobin  attributes  the  tendency  to 
necrosis  and  the  fragility  of  the  bones  of  match-makers.  Arnaud, 
who  has  had  a  very  large  experience  of  industrial  phosphorism,  did  not 
find  this  elevated  coefficient;  in  match-makers  he  found  the  average 
to  be  33-85. 

It  has  been  my  fortune  to  visit  officially  for  the  British  Government 
match  works  in  Britain,  France,  Belgium,  and  Prussia.  I  can  bear  testimony 
to  the  extreme  painfulness  of  phosphor  necrosis,  particularly  in  the  early 
stages.  Extraction  of  the  teeth  gives  no  relief.  The  half  of  the  face  in  time 
becomes  swollen,  and  the  tissues  about  the  jaw  infiltrated.  On  examining 
the  mouth,  the  alveolar  surface  of  the  bone  is  observed  to  be  exposed  and 
covered  with  a  thick  yellowish  slough,  from  which  only  a  small  quantity 
of  pus  escapes.  The  glands  underneath  the  jaw  are  frequently  enlarged, 
and  occasionally  there  is  a  fistulous  opening  under  or  on  the  cheek. 
Necrosis  may  affect  either  jawbone,  more  frequently  the  inferior  maxilla. 
If  the  disease  is  limited  to  the  lower  jaw,  and  is  surgically  treated,  either 
by  gouging  out  a  piece  of  bone  or  resecting  it,  the  patient  is  generally  able 
to  return  to  work  in  about  fourteen  months ;  but  when  necrosis  invades 
the  superior  maxilla,  there  is  a  greater  tendency  for  the  disease  to  spread 


5 go       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

upwards  and  backwards,  and  to  induce  some  brain  affection,  either  a  septic 
meningitis  or  a  cerebral  abscess,  and  which  is  fatal. 

Symptoms. — In  acute  phosphorus  poisoning  the  symptoms  usually 
appear  within  from  one  to  six  hours,  but  their  severity  and  the  period 
at  which  they  appear  depend  upon  the  finely  divided  form  in  which 
the  phosphorus  is  taken,  its  quantity,  and  the  absence  or  presence  of 
fatty  or  oily  food  in  the  stomach  at  the  time.  If  milk  or  fatty  food 
is  present,  it  dissolves  the  poison,  hastens  its  absorption,  and  causes  an 
early  appearance  of  the  symptoms.  Less  than  2  grs.  of  phosphorus 
have  proved  fatal.  Match  heads  contain  phosphorus  varying  in  amount 
from  3*5  to  7'5  mgrms.  ("058  to  -116  gr.),  so  that  the  solution  of  twenty  to 
a  hundred  match  heads  might,  if  drunk,  cause  death. 

For  a  few  hours  after  taking  phosphorus  the  individual  may  move 
about,  and  his  behaviour  be  such  as  not  to  attract  attention,  but  gradually 
abdominal  pain  supervenes,  followed  by  nausea  and  vomiting,  and  then 
the  individual,  on  account  of  pain,  is  forced  to  tell  the  story  of  his 
attempted  suicide.  During  the  act  of  swallowing,  a  disagreeable  taste 
is  experienced  in  the  mouth,  succeeded  by  a  burning  sensation  in  the 
gullet  and  stomach,  and  subsequently  by  retching  and  vomiting.  The 
breath  and  vomited  matter  reek  of  the  odour  of  phosphorus.  The 
vomit  contains  blood  or  biliary  colouring  matter,  and  may  be  luminous 
in  the  dark.  Coffee-ground  vomiting  may  continue  for  two  or  three 
days,  and  be  accompanied  by  diarrhoea.  At  this  stage  the  majority 
of  patients  become  jaundiced,  and  the  rapidity  with  which  this  colora- 
tion of  the  skin  appears  may  be  taken,  as  a  measure  of  the  severity  of 
the  poisoning.  Contemporaneously  with  the  appearance  of  jaundice,  the 
liver  on  percussion  and  palpation  is  observed  to  be  uniformly  en- 
larged and  somewhat  tender,  but  subsequently  it  commences  to  shrink,  a 
circumstance  which,  with  deepening  of  the  jaundice,  suggests  the  prob- 
ability, in  the  absence  of  a  history  of  phosphorus  poisoning,  of  the  case 
being  one  of  acute  yellow  atrophy  of  the  liver.  The  pulse  is  weak  and 
rapid,  frequently  reaching  150  per  minute ;  the  temperature  varies.  A 
high  temperature  is  usually  regarded  as  an  omen  of  death,  but  I  have 
met  with  a  fatal  case  where  the  thermometer  at  this  stage  registered 
only  96°  F.  The  urine  may  be  albuminous ;  it  is  bile-stained,  and 
frequently  contains  crystals  of  leucine  and  tyrosine.  In  some  cases  the 
symptoms  subside,  and  the  improvement  is  permanent ;  in  others,  the 
improvement  is  only  temporary.  Delirium  with  convulsions  or  coma  super- 
venes, indicating,  along  with  deepening  of  the  jaundice,  that  the  patient  is 
no  longer  suffering  from  the  simple  effect  of  the  poison,  but  that  profound 
structural  changes  have  been  established  in  the  liver  and  other  internal 
organs.  In  children  the  illness  may  terminate  fatally  within  the  first  day, 
before  jaundice  has  had  time  to  develop ;  one  of  the  earliest  cases  on  record 
being  reported  in  a  child  set.  8  months,  who  died  within  two  hours  of 
its  mother  pushing  six  matches  down  his  oesophagus.  On  the  average, 
death  supervenes  about  the  seventh  day. 

The  acute  form  of  poisoning  just  described  corresponds  to  the  common 
variety  of  Tardieu,  in  which  the  symptoms  are  irritant,  nervous,  and 
hemorrhagic.  Nervous  symptoms  occasionally  predominate,  there  being, 
in  addition  to  the  vomiting  and  abdominal  pain,  cramp-hke  feelings  in 
the  legs,  with  loss  of  power,  or  delirium  with  convulsions,  but  without 
jaundice.  Usually  the  skin  is  the  seat  of  well-marked  icterus,  erythema, 
or  petechial  haemorrhages.     The  liver  is  enlarged.     Von  Jaksch  found  the 


PHOSPHORUS  POISONING  591 

alkalinity  of  the  blood  diminished,  and  the  coloured  discs  temporarily 
increased  in  size.  Munzer  also  found  the  blood  less  alkaline  than  in 
health,  and  attributed  the  fact  to  an  increased  production  of  acids  within 
the  body.  It  seemed  to  him  that  both  the  red  and  white  blood  corpuscles 
were  normal  in  size,  but  that  the  red  were  increased  in  number.  There  is 
considerable  discrepancy  among  writers  as  to  the  effect  of  phosphorus 
upon  the  blood.  Biiiz,  quoting  as  his  authority  Dybkowsky,  says  that  the 
red  blood  corpuscles  of  man  undergo  no  change.  Whatever  may  be  the 
primary  effect  of  phosphorus  upon  the  blood,  it  is  now  generally  admitted 
that  secondarily  the  number  of  the  coloured  discs  is  diminished.  The 
blood,  too,  is  of  a  darker  colour,  and  is  not  so  liable  to  coagulate  as  in 
health. 

The  urine  may  be  albuminous  and  bile-stained,  but  sugar  as  a  rule  is 
absent.  Tyrosin,  if  present,  must  be  regarded  as  an  indication  of  the 
existence  of  structural  changes  in  the  liver,  tending  to  fatty  degeneration 
and  atrophy.  On  microscopical  examination  of  the  kidney,  the  epithelium 
is  found  to  be  fatty,  and  hyaline  tube  casts,  which  are  often  bile-stained, 
may  be  observed  in  situ.  Munzer  found  crystals  of  hsematoidin  in  the 
urine,  also  traces  of  sarcolactic  acid.  A  transitory  peptonuria  is  alluded 
to  by  some  authors,  and  a  fall  in  the  total  nitrogen  ehminated  in  the 
early  stages  is  vouched  for  by  von  Jaksch,  and  corroborated  by  my 
own  experience.  Subsequently  the  nitrogenous  waste  in  the  urine,  as 
indicated  by  uric  acid  and  ammonia,  may  be  increased,  the  ammonia  play- 
ing, according  to  Munzer,  a  useful  part  in  the  economy,  by  neutralising 
the  acid  products  formed  in  excess  through  the  action  of  phosphorus 
upon  the  tissues.  Phosphoric  acid,  if  present  in  the  urine  in  excess  in 
the  early  stages,  subsequently,  along  with  the  sulphuric  acid,  sinks 
below  the  normal.  So  long  as  jaundice  is  present,  the  faeces  are  pale: 
they  may  contain  phosphorus,  and  emit  a  garlicky  odour.  Pregnant 
women  usually  miscarry,  the  foetus  as  a  rule  being  still-born.  There  is 
nothing  unusual  in  the  course  of  the  labour  in  such  a  case,  but  once  it  is 
completed  the  jaundice  is  frequently  observed  to  deepen  in  tint,  the  liver 
becomes  more  tender,  and  rapidly  shrinks  in  size.  Somnolence  develops, 
and  the  patient  dies  comatose. 

Diagnosis.  —  When  the  liver  is  shrunken  and  jaundice  well 
marked,  phosphorus  poisoning  resembles  acute  yellow  atrophy  of  the  liver. 
Delirium  and  coma  are  perhaps  not  just  so  pronounced  in  phosphorus 
poisoning,  and  there  is  less  tendency  for  the  spleen  to  be  enlarged.  It  is 
noteworthy,  too,  that  whilst  in  acute  yellow  atrophy  the  liver  decreases 
rapidly  in  size,  and  the  jaundice  deepens  in  proportion,  in  phosphorus 
poisoning,  on  the  other  hand,  the  jaundice  appears  with  the  enlargement 
of  the  liver  and  runs  parallel  with  it.  The  urine  is  more  likely  to  contain 
leucine  and  tyrosine  in  acute  yellow  atrophy,  the  leucine  appearing  as 
small  spheres,  not  unlike  droplets  of  fat,  and  tyrosine  as  delicate  needle- 
like  crystals.  At  the  autopsy  it  has  sometimes  been  impossible  to  dis- 
tinguish between  the  two  diseases.  There  are  physicians  who  maintain 
that,  apart  from  phosphorus  poisoning,  there  is  no  such  independent  disease 
as  acute  yellow  atrophy  of  the  liver.  Vivian  Poore  holds  that  clinically 
and  pathologically  the  two  conditions  are  indistinguishable. 

Hypertrophic  cirrhosis  of  the  liver  may  resemble  subacute  phosphorus 
poisoning,  especially  if  it  is  rapidly  developed  and  leads  to  death  through 
cholgemia.  No  reliance  can  be  placed  upon  the  sanguineous  vomit  nor 
enlargement  of  the  spleen,  which  is  said  by  some  to  be  present  in  hyper- 


592        DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

trophic  cirrhosis  as  differentiating  the  disease  from  phosphorus  poisoning, 
for  after  all  these  are  not  always  present  in  hypertrophic  cirrhosis.  The 
recurrence  of  convulsions  or  rigors,  a  high  temperature,  albuminuria,  splenic 
enlargement,  and  the  history  of  the  case,  would  help  to  distinguish  puerperal 
eclampsia  with  jaundice,  also  certain  forms  of  alcoholic  and  ursemic  intoxi- 
cation, and  septic  infection  from  phosphorus  poisoning.  The  odour  of 
phosphorus  in  the  vomit  and  faeces  wTould  settle  the  diagnosis  of  acute 
poisoning. 

Prognosis.  — The  prognosis  of  phosphorus  poisoning  is  grave,  the  grav- 
ity being  proportional  to  the  dose  taken.  Nearly  40  per  cent,  of  the  patients 
die,  some  within  two  or  three  days  after  taking  the  poison,  others  several 
days  afterwards  and  rather  suddenly,  from  syncope  due  to  fatty  degenera- 
tion of  the  cardiac  muscle  fibre ;  while  others,  again,  die  in  a  state  of  delirium 
and  coma,  the  early  appearance  of  which,  along  with  the  jaundice,  must  be 
regarded  as  a  measure  of  the  severity  of  the  illness. 

Treatment. — If  seen  early,  emetics  and  purgatives  should  be  at  once 
administered,  in  the  hope  of  preventing  absorption,  for  once  this  has  taken 
place  it  is  impossible  to  control  the  organic  changes  that  follow.  To  be 
efficacious,  treatment  should  be  resorted  to  at  once,  and  be  continued.  Wash- 
ing out  the  stomach  with  an  abundant  supply  of  lukewarm  water  is  at 
once  called  for,  until  all  odour  of  phosphorus  has  disappeared,  and  adding 
to  the  final  lavage  copper  sulphate  (1  in  100),  since  this  forms,  with  any 
phosphorus  left  in  the  stomach,  an  insoluble  phosphide  of  copper.  Von 
Jaksch  recommends  irrigation  of  the  stomach  with  water  containing 
gelatin  and  magnesia,  others  use  potassium  permanganate,  whilst  Andant 
and  Personne  speak  highly  of  the  essence  of  terebinthin  in  capsules,  1  to 
2  drms.  in  twenty-four  hours.  In  tins  country  the  administration  of  oil  of 
turpentine  in  40-drop  doses,  though  not  so  beneficial  as  the  old  French 
oleum  terebinth,  gives,  on  the  whole,  satisfactory  results.  This  is  due 
to  the  fact  that  phosphorus,  having  a  great  affinity  for  oxygen,  combines 
with  the  nascent  oxygen  in  the  turpentine,  forming  a  harmless  compound, 
probably  phosphoric  acid.  All  fatty  food,  such  as  milk,  and  oily  emulsions, 
which  rapidly  dissolve  phosphorus,  must  be  interdicted.  Saline  aperients 
are  necessary,  even  after  the  use  of  emetics  and  the  stomach-pump,  but 
castor-oil  must  be  avoided. 

In  the  later  stages,  when  the  heart  has  undergone  degeneration  and 
there  is  faintness,  stimulants  should  be  administered  with  or  without  the 
hypodermic  injection  of  digitalin,  ether,  etc. 

The  treatment  of  phosphorism,  as  observed  among  match-makers,  is 
preventive  and  curative.  Ill  health  would  practically  disappear,  if  red 
phosphorus  were  substituted  for  yellow  in  the  manufacture  of  matches. 
In  Denmark  the  use  of  yellow  phosphorus  in  match-making  is  interdicted. 
Other  nations  are  moving  in  a  similar  direction,  and  are  either  insisting 
upon  matches  being  made  in  closed  machines,  or  of  replacing  the  white  by 
the  harmless  red  phosphorus.  Kassner,  a  Frenchman,  has  invented  matches 
made  of  plumbate  of  calcium,  which,  while  retaining  all  the  advantages, 
have  none  of  the  disadvantages  observed  in  those  made  from  phosphorus. 
In  France  matches  are  now  made  from  the  harmless  sesqui-sulphide  of 
phosphorus.  Enfeebled,  poverty-stricken,  and  intemperate  people  should 
not  be  allowed  to  enter  upon  or  continue  at  the  trade.  The  workshops 
should  be  well  ventilated.  Personal  cleanliness  should  be  insisted  upon, 
and  there  should  be  frequent  dental  examination  of  the  teeth  and  gums, 
so  that,  in  the  event  of  carious  teeth  being  detected  in  an  individual,  he 


MERCURIAL  POISONING  593 

should  be  obliged  to  retire  from  the  factory.  For  the  early  stages  of  phos- 
phorus necrosis  or  "phossy  jaw,"  as  it  is  sometimes  called  in  this  country, 
"mal  chimiquc"  as  it  is  known  in  France,  antiseptic  mouth-washes  are 
necessary.  Magitot  and  Eoussel  believe  that  caries  of  the  teeth  precedes 
the  necrosis,  and  that  this  allows  of  the  penetration  of  the  phosphorus 
fumes,  whereby  periostitis  is  induced ;  but  Dubois  states  that  he  has 
never  observed  any  primary  dental  lesion  or  any  affection  of  the  gums  in 
match-makers.  Riedel  maintains  that  in  phosphorism,  periostitis  ossificans 
of  the  jawbone  may  occur  before  there  is  necrosis,  if  the  teeth  are  good. 
Once  necrosis  is  established,  medicine  does  no  good.  Early  surgical  inter- 
vention is  advised  by  the  German  surgeons,  Kiedel,  Langenbeck,  Pitha, 
and  Billroth,  who  are  in  favour  of  complete  resection  of  the  jaw ;  but 
English  and  French  surgeons  prefer  to  wait  until  the  sequestrum  is 
removable.  Among  the  lucifer  match-makers  of  the  East  End  of  London, 
Garman  found  that  he  got  less  deformity  of  the  face  when  the 
sequestrum  was  allowed  to  come  away  of  its  own  accord,  and  that  the 
rate  of  mortality  was  lower  than  when  the  cases  were  treated  surgically. 


MEECUPJAL  POISONING. 


Etiology. — Poisoning  by  mercury  may  be  acute  or  chronic.  The 
chronic  form  hydrargyria,  or  mercurialism,  is  observed  among  the  miners 
and  smelters  of  quicksilver,  in  people  who  handle  the  metal  or  inhale  its 
vapour  during  the  manufacture  of  mirrors,  barometers,  and  thermometers, 
also  among  felt  hat  makers  and  furriers.  Some  persons  have  a  greater 
susceptibility  to  the  poison  than  others.  Women  and  young  children 
are,  if  anything,  more  liable  to  be  affected  by  it,  also  people  suffering  from 
kidney  disease,  and  those  who  are  scrofulous.  Eigler  states  that  opium- 
eaters  can  take  fairly  large  doses  of  corrosive  sublimate  with  greater  im- 
punity. The  metal  gains  access  to  the  system  by  absorption  through 
the  skin,  by  inhalation  of  the  vapour,  and  by  workmen  eating  with  un- 
washed hands. 

Acute  mercurial  poisoning  is  chiefly  suicidal,  and  in  this  country  is 
responsible  for  about  five  deaths  every  year.  During  ten  years  ending 
1892,  fifty-nine  deaths  occurred  in  England  from  mercury,  mostly  from 
corrosive  sublimate,  namely,  forty  males  and  nineteen  females ;  and  of  these 
there  were  sixteen  males  and  eighteen  females  whose  poisoning  was  suicidal. 
The  toxic  effects  of  all  the  mercurial  compounds  are  similar,  but  as  cor- 
rosive sublimate  produces  the  most  violent  symptoms,  it  is  generally  taken 
as  the  type  of  this  form  of  poisoning. 

Mercury  comes  into  this  country  in  the  form  of  sulphide  or  cinnabar, 
from  which,  either  by  roasting  the  ore  or  reducing  it  with  iron  and  lime, 
metallic  vapour  is  given  off,  which  readily  condenses.  Until  lately,  most 
of  the  mercury  came  from  Almaden  in  Spain,  but  California  as  a  producer 
has  lately  rivalled  Spain.  It  has  been  known  for  centuries  that  the  fumes 
of  the  metal  have  at  Almaden  played  havoc  with  the  workpeople  and 
vegetation.  As  it  was  difficult  to  get  men  to  work  in  the  mines  or  at  the 
smelting  furnaces,  gangs  of  convicts  had  to  be  imported,  but  as  their  habits 
were  even  less  cleanly  than  those  of  the  ordinary  workmen,  they  readily 
fell  victims  to  the  unhealthy  air  of  the  mines,  or  the  heavily  laden 
vol.  1. — 18 


594       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

atmosphere  of  the  smelting  rooms.  The  application  of  better  sanitary  laws, 
and  the  introduction  of  improved  methods  of  mining  and  smelting,  which 
the  wealth  of  California  allows  of,  have  in  the  United  States  largely 
contributed  to  the  obviation  of  many  of  those  objectionable  conditions 
to  the  operation  of  which  much  of  the  ill-health  of  the  Spanish  miners 
was  attributed. 

It  is  owing  to  its  ready  volatilisation  that  mercury  is  such  a  dangerous 
metal  in  the  industries.  Workmen  exposed  to  its  vapour  at  a  low  temperature 
scarcely  suffer,  but  mercury  begins  to  volatilise  at  8°"5  F.,  and  the  danger 
increases  with  elevation  of  the  temperature.  It  readily  forms  an  amalgam 
with  other  metals,  from  which  it  can  be  easily  separated  by  distillation.  Thus, 
united  with  gold  or  silver,  it  was  used  by  water-gilders  for  depositing  gold 
on  metallic  surfaces,  also  in  mirror-silvering,  processes  which  were 
attended  by  a  considerable  amount  of  ill-health  on  the  part  of  those  thus 
employed.  Water-gilding  has  lately  been  superseded  by  electro-plating, 
and  the  silvering  of  mirrors  is  now  accomplished  by  pouring  a  mixture  of 
tartaric  acid  and  silver  nitrate  on  glass,  and  exposing  it  to  the  air,  when 
the  silver  becomes  deposited.  In  my  visits  to  the  largest  glass-works 
of  this  country,  I  have  observed  that  since  the  adoption  of  the  new 
method  of  silvering  mirrors,  workmen  no  longer  suffer ;  but  in  going 
through  boot  and  shoe  factories,  where  American  sole-stitching  machines 
are  employed,  my  attention  has  been  drawn  to  supposed  symptoms  of- 
mercurialism  among  men  who  work  these  machines,  owing  to  mercurial 
vapour  arising  from  a  well  or  movable  joint  which  is  filled  with  quicksilver. 

Poisoning  is  also  observed  among  hatters  in  Germany  and  America. 
Felt  is  made  from  the  furs  of  various  animals,  e.g.  the  beaver,  rabbit,  and  hare ; 
whilst  coarser  kinds  are  made  from  wool  and  cotton.  Furs  blend  and  adhere 
better  after  felting,  if  they  have  been  treated  with  a  strong  solution  of  acid 
nitrate  of  mercury.  This  is  accomplished  by  brushing  the  fur  with  the 
mercury,  a  process  which  at  this  stage  is  not  dangerous.  The  danger 
arises  subsequently  when  the  felt  is  being  made  into  hats  or  is  being 
finished,  for  at  this  stage  a  considerable  amount  of  dust  is  given  off ;  it  is 
likewise  present  when  the  finished  material  is  subjected  to  great  heat, 
for  then  mercurial  vapours  escape.  As  a  class,  hat  makers  show  a  higher 
mortality  than  most  of  the  o^her  trades,  their  death-rate  in  England  being 
1064  to  1000  of  all  males. 

Among  other  causes  of  accidental,  suicidal,  or  homicidal  mercurial 
poisoning  from  corrosive  sublimate,  may  be  mentioned  the  external  applica- 
tion of  nitrate  of  mercury,  the  absorption  through  the  skin  of  certain  salts, 
e.g.  the  oleate,  also  the  employment  by  surgeons  and  accoucheurs  of  too 
strong  solutions  of  the  perchloride  as  a  germicide  in  washing  out  the 
internal  cavities  of  the  body. 

Morbid  anatomy. — If  a  person  has  died  from  corrosive  sublimate 
poisoning,  there  is  escharotic  whitening  of  the  mouth,  throat,  and  gullet ; 
there  is  considerable  destruction  of  the  mucous  membrane,  or  it  is 
ecchymosed  all  the  way  down  the  intestinal  tract  to  the  anus.  Irrespect- 
ive of  the  channel  by  which  mercury  has  gained  entrance  into  the  system, 
the  intestine-  usually  contains  a  large  quantity  of  yellowish  brown  or 
sanguinolent  liquid,  accompanied  by  flakes  of  mucous  membrane.  The 
kidneys  are  hypersemic,  and  the  renal  tubules  contain  chalky  masses,  con- 
sequent upon  decalcification  of  the  bones,  and  a  subsequent  deposition  of 
lime  salts  in  the  kidneys.  In  animals  experimentally  poisoned  by  the 
injection  of   peptonate  of  mercury,  death  supervened  too   rapidly  from 


MERCURIAL  POISONING.  595 

paralysis  of  the  heart  for  pathological  changes  to  be  observed  ;  but  in 
•cases  where  life  for  a  time  was  maintained,  the  myelin  sheath  of  the 
peripheral  nerves  was  found  fatty,  and  in  the  spinal  cord  there  was 
observed  a  limited  myelitis.  In  mercurial  encephalopathy  there  have 
been  found  cerebral  oedema,  fluid  in  the  subarachnoid  and  ventricular 
spaces  with  arterio-sclerosis,  and,  on  chemical  analysis,  mercury  has  been 
found  in  the  brain. 

Symptoms. — In  people  who  have  been  exposed  to  the  vapour  of 
mercury,  tremor  is  frequently  observed.  Commencing  usually  in  the 
upper  extremities,  it  spreads  to  voluntary  muscles,  and  in  doing  so  in- 
creases in  amplitude,  ultimately  assuming  a  choreiform  character.  The 
movements  are  aggravated  by  emotion,  and  generally  cease  during  sleep. 
There  may  be  paralysis,  and  if  so,  the  tremor  may  be  entirely  confined  to 
the  muscles  thus  affected.  Although  their  electrical  reaction  is  diminished, 
the  muscles  do  not  exhibit  any  qualitative  changes  to  the  galvanic  current. 
Want  of  personal  cleanliness,  ill-feeding,  and  the  abuse  of  alcoholic 
stimulants,  on  the  part  of  the  work-people,  predispose  to  tremor.  The  gums 
become  swollen,  ulcerated,  and  tend  to  bleed,  the  teeth  become  loose  and 
fall  out.  The  salivary  glands  are  excited  to  unwonted  activity,  either  re- 
flexly  by  irritation  of  the  tongue,  which  feels  too  large  for  the  mouth, 
by  stimulation  of  the  nerves  that  supply  the  glands,  or  by  changes  in  the 
glands  themselves,  for  these  are  enlarged  and  painful.  The  breath  is 
foetid,  and  there  is  complaint  of  a  disagreeable  taste  in  the  mouth.  The 
changes  in  the  gums  occur  without  pain  or  fever.  The  miners  at 
Almaden  used  to  regard  the  loss  of  their  teeth  as  likely  to  give  them 
exemption  from  further  trouble,  but  the  shedding  of  the  teeth  destroyed 
their  power  of  mastication,  and  so  altered  their  facial  expression  that 
while  they  were  still  young  they  looked  like  old  men.  Add  to  tremor 
and  loss  of  teeth,  the  presence  of  anaemia  or  cachexia,  bronzing  of  the  skin, 
a  rash  known  as  "  eczema  mercuriale,"  diarrhoea,  rheumatic  pains  in  the 
joints,  and  foetid  breath,  symptoms  which  are  spoken  of  as  those  of 
mercurial  scurvy ;  also  a  tendency  for  pregnant  females  to  abort,  and  the 
children  born  of  affected  parents  dying  largely  from  phthisis,  and  we  have 
a  symptomatology  which  is  characteristic  of  chronic  mercurialism. 

Occasionally,  the  paralysis  is  limited  to  one  or  a  few  muscles,  and 
is  accompanied  by  an  alteration  of  speech,  which  becomes  staccato  and 
stammering.  The  loss  of  power  is  preceded  by  pain,  suggesting  peripheral 
neuritis,  or  there  is  surface  anaesthesia,  which  suggests  hysteria.  There 
may  be  other  symptoms  too,  such  as  are  observed  in  hysteria,  namely, 
hemiplegia,  hemianaesthesia,  and  amblyopia.  Several  of  these  cases  have  in 
the  hands'  of  Letulle  rapidly  yielded  to  suggestion,  clearly  indicating  that 
there  could  not  have  been  in  the  nervous  system  any  organic  lesion.  A 
low  form  of  encephalopathy  is  occasionally  developed  in  mercurialism, 
in  which  the  intellectual  powers  become  blunted,  the  mental  faculties  lose 
their  sharpness,  and  sleeplessness  supervenes,  followed  by  insanity.  The 
special  senses  do  not  always  escape.  There  may  be  amblyopia,  or  optic 
atrophy. 

After  swallowing  a  large  dose  of  corrosive  sublimate,  severe  symptoms 
appear  usually  within  half  an  hour.  The  bichloride  is  a  powerful  poison. 
Three  grains  have  proved  fatal.  The  patient  complains  of  a  burning  heat 
in  the  throat,  with  a  sense  of  constriction  during  the  act  of  swallowing 
the  poison.  There  is  pallor  of  the  mucous  membranes  with  shrivelling, 
great  pain  in  the  stomach,  profuse  diarrhoea,  and  bloody  vomiting ;  marked 


596       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

fall  of  the  temperature,  small  and  irregular  pulse,  scanty  urine,  extreme 
prostration  and  collapse,  oedema  of  the  glottis,  followed  by  difficult  breath- 
ing and  asphyxia,  leading  to  death,  which  may  be  preceded  by  convulsions 
or  be  due  to  syncope.  Some  people  are  extremely  easily  influenced  by 
mercury.  As  illustrating  this  susceptibility,  I  will  mention  one  case,  that  of 
a  girl,  aged  18  years,  who  was  suffering  from  anaemia.  I  ordered  her  2  grs. 
of  calomel.  After  a  second  dose  of  2  grs.,  taken  several  days  after  the 
first,  the  patient  was  severely  mercurialised.  She  had  headache,  inflamed 
eyes,  salivation,  and  painful  ulceration  of  the  gums. 

Diagnosis. — The  history  of  the  case,  and  particularly  if  the  poisoning 
is  acute,  the  presence  of  white  eschars  in  the  mouth,  extreme  pain  at  the 
epigastrium,  sanguinolent  vomiting,  and  diarrhoea  with  collapse,  suggest 
the  probability  that  corrosive  sublimate  has  been  taken.  The  tremor 
observed  in  a  chronic  case  is  not  unlike  that  of  disseminated  sclerosis,  but 
there  is  neither  the  nystagmus  nor  the  exaggerated  reflexes  noticed  in 
that  disease,  whilst  the  tremor,  similarly  exaggerated  under  volition,  is  much 
less  in  amplitude.  Speech  in  both  illnesses  may  be  affected,  but  it  is  more 
a  stuttering  in  chronic  mercurialism  than  the  slow  syllabic  speech  observed 
in  disseminated  sclerosis.  Hydrargyria  may  simulate  progressive  general 
paralysis,  but  there  are  no  grandiose  ideas,  although  there  is  mental 
irritability ;  no  inequality  of  the  pupils ;  and  although  tremor  is  present 
in  both,  it  is  distributed  all  over  the  body  in  mercurialism,  whereas  it  is 
confined  to  the  lips,  tongue,  and  hands,  in  general  paralysis.  It  may  be 
difficult  to  distinguish  between  chronic  mercurialism  and  lead  poisoning,  if 
tremor  is  the  only  symptom ;  but  in  the  history  of  colic,  the  presence  of  a 
blue  line  on  the  gums,  and  in  the  results  of  an  examination  of  the  urine 
for  lead  or  mercury,  an  answer  to  the  problem  will  be  found. 

Prognosis. — In  acute  poisoning  by  corrosive  sublimate,  tne  prognosis 
depends  upon  the  dose  swallowed  and  the  severity  of  the  symptoms. 
It  is  grave  as  a  rule.  In  chronic  mercurialism,  unless  the  individual  has 
been  too  long  exposed  to  the  fumes  of  the  metal,  he  generally  does  well, 
if  removed  from  the  cause  of  his  illness.  In  chronic  cases,  life  is  only 
threatened  when  the  kidneys  have  become  profoundly  affected,  or  where 
the  brain  is  the  seat  of  mercurial  deposition.  Tremor  once  established 
may  never  entirely  disappear,  but  its  persistence  need  cause  no  anxiety. 

Treatment. — The  treatment  of  chronic  mercurialism  is  preventive 
and  curative,  whilst  that  for  corrosive  sublimate  is  largely  the  employment 
of  the  ordinary  remedies  useful  in  acute  irritant  poisoning.  In  the  case  of 
work-people  exposed  to  the  fumes  of  the  metal,  it  may  be  impossible  to 
prevent  some  degree  of  poisoning ;  but  good  ventilation,  personal  cleanli- 
ness, washing  of  the  hands  before  eating,  the  frequent  use  of  baths, 
working  in  cool  rooms  to  prevent  perspiration,  no  food  to  be  eaten  in 
the  workrooms,  and  change  of  occupation  on  symptoms  showing  them- 
selves, are  regulations  which,  when  followed,  will  largely  diminish  industrial 
mercurialism.  Mouth  washes  composed  of  weak  carbolic  or  boracic  acid, 
or  of  potassium  chlorate,  myrrh  and  quassia,  are  advantageous  where  the 
gums  are  soft  and  ulcerating.  Iodide  of  potassium  has  the  reputation  of 
favouring  the  elimination  of  mercury,  but  it  should  be  given  carefully, 
commencing  with  small  doses,  so  as  not  to  throw  at  one  time  too  much  of 
the  metal  redissolved  from  the  tissues  into  the  circulation.  Milk  diet 
favours  elimination  by  the  kidneys.  Sulphur  baths  are  recommended, 
but  they  are  doubtfully  efficacious,  and  for  the  paralysis  and  muscular 
weakness,   electricity   and   massage,   employing   the   galvanic   current  in 


ALCOHOLIC  POISONING.  597 

the  early  stages,  and  subsequently,  when  the  muscles  are  atrophied, 
faradism. 

In  acute  poisoning,  treatment  may  be  unavailing,  but  advantage  is 
taken  of  the  fact  that  mercury  forms  with  albuminous  bodies  insoluble 
compounds,  to  administer  milk  and  white  of  egg.  The  stomach  must  be 
thoroughly  washed  out,  and  vomiting  encouraged,  either  by  subcutaneous 
injection  of  4  drop  doses  of  apomorphine,  or  by  zinc  sulphate  given  by 
the  mouth.  For  severe  pain  morphia  must  be  administered,  and  for 
collapse  stimulants  or  caffeine  by  the  rectum.  Occasionally  the  symptoms 
subside,  and  while  the  patient  is  apparently  progressing  there  is  a  return 
of  the  dysenteric  discharges,  accompanied  by  ptyalism  and  great  debility, 
to  which  the  patient  may  succumb.  If  decalcification  of  bones  is  taking 
place,  lime  salts  should  be  given,  e.g.  calcium  phosphate. 

In  obstetrical  practice,  too  free  irrigation  of  the  uterine  cavity,  with  even 
weak  solutions  of  bichloride  of  mercury,  has  caused  symptoms  of  poisoning. 
It  is  noteworthy  that  nearly  one-half  of  those  who  have  suffered  were 
primiparse.  Bichloride  of  mercury  should  not  be  used  where  the  mother  is 
ansemic  or  debilitated,  as  a  consequence  of  her  pregnancy  or  from  haemor- 
rhages ;  and  the  accoucheur  should  be  quite  sure  of  the  integrity  of  the 
kidneys,  as  experience  has  shown  how  susceptible  renal  patients  are  to  the 
influence  of  mercury. 


ALCOHOLIC   POISONING. 


Etiology". — There  is  no  product  of  human  ingenuity  more  widely  dis- 
tributed throughout  the  world  than  alcohol.  Almost  every  nation  has  its 
alcoholic  beverage,  or  its  stimulant  and  narcotic.  It  is  to  the  effects  caused 
by  the  immoderate  use  of  alcohol  that  we  intend  particularly  to  refer.  The 
word  itself  shows  how  conscious  the  Arabs  of  old  were  of  its  effects  when 
they  named  it  alcohol — cd  the,  and  Kohol  secret,  or  subtle  thing — the  use 
of  which  robbed  the  individual  of  his  senses.  All  the  alcohols  are 
poisons.  The  four  most  important,  and  they  are  given  in  the  order  of 
increasing  toxicity,  are  —  (1)  methylic  alcohol,  a  wood  spirit;  (2) 
ethylic  alcohol,  or  spirit  of  wine;  (3)  propylic;  and  (4)  amylic  alcohol, 
fusel  oil,  or  potato  spirit.  Spirit  of  wine,  usually  spoken  of  as  alcohol,  the 
prefix  ethylic  being  omitted,  is  obtained  from  the  alcoholic  fermentation  of 
sugar.  It  always  contains  water,  part  of  which  only  is  removable  by 
redistillation,  for  the  strongest  rectified  spirit  usually  contains  from  13  to 
16  per  cent,  of  water.  A  further  portion  of  the  water  can  be  removed  by 
distillation  with  quicklime.  When  thus  purified,  it  is  called  absolute  alcohol, 
and.  contains  1  per  cent,  of  water.  Methylic  alcohol,  or  wood  naphtha,  is 
obtained  from  the  dry  distillation  of  wood ;  while  methylated  spirit  is  a 
mixture  of  nine  parts  of  ethylic  alcohol  (spirits  of  wine)  and  one  part 
methylic.  The  percentage  of  alcohol  in  spirituous  beverages  varies: 
whisky,  brandy,  and  gin  contain  from  50  to  60  per  cent. ;  port  and 
sherry,  15  to  20 ;  claret  and  burgundy,  10  to  17 ;  champagne,  6  to  13 ;  ale 
and  porter,  4  to  6  per  cent.  Alcohol  is  a  colourless  limpid  fluid,  with 
a  pungent  taste  and  agreeable  smell;  it  has  a  strong  attraction  for 
water,  whether  in  the  air  or  in  the  tissues  of  an  animal,  and  is  easily 
converted  by  oxidation  into  aldehyde  and  water,  and  subsequently  into 
acetic  acid. 


593       DISEASES  CAUSED  BY  CHEMICAL  SUBSTA2VCES. 

Morbid  anatomy  and  pathology. — Alcohol  is  a  narcotic  poison, 
which  exercises  its  pernicious  influence  principally  upon  the  brain,  as  witness 
simple  intoxication,  in  which  the  various  centres  in  the  brain  at  particular 
levels  become  successively  involved.  After  death  from  coma,  in  acute 
alcoholic  poisoning,  the  brain  and  its  membranes  are  found  injected,  and  there 
is  inflammatory  redness  of  the  mucous  membrane  of  the  stomach  and  duo- 
denum. In  the  bodies  of  chronic  drinkers,  degenerative  changes  are  found 
widely  distributed.  The  liver  is  fatty  or  cirrhotic ;  the  spleen  is  enlarged 
and  contains  excess  of  connective  tissue ;  the  gastric  mucous  membrane  is 
congested ;  the  heart  is  dilated  and  its  muscle  fibres  soft  and  flabby;  the 
aorta  is  atheromatous  and  dilated.  Sometimes  the  membranes  of  the 
brain  are  thickened  and  adherent  at  the  vertex ;  the  pia  mater  is  opaque. 
This  pachymeningitis  causes  flattening  of  the  cerebral  convolutions,  the  blood 
vessels  dipping  into  which  are  often  found  to  be  tortuous  and  degenerated.  ■ 
On  microscopical  examination,  the  large  cells  in  the  cortex  of  the  motor  areas 
show  degenerative  changes,  along  with  vacuolation  of  their  protoplasm,  whilst 
their  dendritic  processes  are  varicose,  and  the  surrounding  neuroglia  is 
increased.  Similar  changes  may  be  observed  in  the  spinal  cord,  affecting 
principally  .the  ganglion  cells.  In  the  peripheral  nerves  of  alcoholic 
paralytics  there  is  frequently  found  excessive  growth  of  the  connective 
tissue  framework,  leading  to  atrophy  of  the  nerve  fibrils.  It  is  an  interest- 
ing fact  as  bearing  upon  the  relation  of  alcoholic  insanity  and  a  predis- 
posed state  of  the  nervous  system,  probably  hereditarily  acquired,  that- 
in  the  experience  of  asylum  pathologists,  cirrhosis  of  the  liver,  which 
in  infirmary  practice  is  one  of  the  most  common  effects  of  alcoholic 
intemperance,  is  almost  never  met  with.  This  circumstance  indicates 
that  long  before  the  effects  of  alcohol  have  had  time  to  induce  pathological 
changes  in  the  liver,  the  nervous  system,  being  unstable,  has  already  become 
affected.  _ 

Symptoms. — The  most  common  form  of  acute  alcoholism  is  intoxica- 
tion. This  in  its  milder  varieties  involves  the  motor  apparatus,  and  the  organs 
of  the  ordinary  and  special  senses.  It  is  associated  with  varying  mental 
phenomena,  and  when  pushed  further  causes  coma,  or  such  a  degree  of,  excite- 
ment of  the  brain  as  to  lead  to  insanity.  One  of  the  earliest  effects  of  the 
imbibition  of  alcohol  is  relaxation  of  the  blood  vessels ;  this  is  accompanied 
by  a  sense  of  warmth  and  a  general  feeling  of  pleasure.  The  brain  for  the 
moment  works  faster,  so  that  ideation  is  increased,  but  even  at  this  stage  the 
individual  has,  owing  to  vasomotor  paralysis,  lost  to  some  extent  his  control. 
There  is  emotional  excitement,  and  for  the  time  being  the  individual  is 
another  ego.  The  man  who  is  ordinarily  quiet,  retiring,  and  inoffensive,, 
becomes,  under  the  influence  of  drink,  obtrusive,  talkative,  and  querulous : 
his  articulation  becomes  indistinct,  his  words  are  apt  to  be  slurred  and  in- 
terrupted, and  should  he  be  sitting  and  attempt  to  rise,  he  staggers,  owing 
to  muscular  inco-ordination.  In  the  more  advanced  stages  of  drunkenness 
the  intellectual  powers  as  well  as  the  motor  may  be  so  depressed,  that  the 
individual  lies  in  a  helpless  and  unconscious  condition,  his  life  being 
solely  dependent  upon  the  activity  of  his  respiratory  and  cardiac  centres. 
Hughlings  Jackson,  in  his  application  of  Herbert  Spencer's  theory  of 
evolution  to  the  nervous  system,  remarks  that  evolution  is  an  ascending 
development  in  a  particular  order,  and  is  a  passage  from  the  most  to  the 
least  organised,  i.e.  to  say  from  the  lowest,  well  organised  centres  to  the 
highest,  least  organised  centres,  or,  in  other-  words,  a  progress  from  centres 
which  are  comparatively  well  organised  at  birth  to  those  highest  centres 


ALCOHOLIC  POISONING.  599 

which  are  continually  organising  through  life.  It  is  a  passage  from  the 
most  automatic  to  the  most  voluntary.  The  reverse  of  this  is  dissolution, 
a  process  which  consists  in  "  taking  to  pieces,"  in  the  order  from  the  most 
voluntary  to  the  simplest  and  most  automatic.  In  dissolution  the  centres 
are  not  all  evenly  affected,  and  the  action  of  alcohol  exemplifies  this.  The 
highest  centres,  because  they  are  the  least  organised,  give  out  first  and 
most ;  the  middle  centres,  being  more  organised,  resist  longer ;  while  the 
lowest  centres,  being  most  organised,  resist  the  longest.  Hence  are  explained, 
as  the  results  of  alcoholic  intoxication — (a)  the  disorder  of  the  intellectual 
and  emotional  facidties;  (b)  loss  of  co-ordination;  and  (c)  the  coma  of 
an  individual  who  is  dead  drunk,  and  in  whom  life  is  but  the  expression  of 
the  automatic  activities  of  cardiac  and  respiratory  centres.  Did  these 
lowest  centres,  which  are  well  organised,  not  resist  the  longest,  death  by 
large  doses  of  alcohol  would  be  frequent.  As  the  cardiac  centre  during 
embryological  development  is  laid  down  in  the  foetus  before  the  respirat- 
ory, it  is  therefore  the  more  highly  organised,  and  it  remains  active 
to  the  last  in  alcoholic  poisoning,  constituting  the  ultimum  moriens. 

"Where  a  large  quantity  of  strong  spirit  has  been  drunk  in  a  short  space 
of  time,  or  is  taken  by  people  exhausted  by  fatigue  or  chilled  by  cold,  coma 
is  quickly  developed,  the  face  becomes  pale,  the  pupils  dilate,  the  tem- 
perature rapidly  falls  below  the  normal,  the  pulse  becomes  thready,  and 
the  breathing  stertorous.  Death  may  follow  within  a  few  hours.  One  cold 
Xew  Year's  Eve  I  remember  being  called  to  see  a  man  who  had  swallowed 
within  the  space  of  a  few  minutes  a  large  bottleful  of  whisky;  he  had 
quickly  become  unconscious,  and  was  dead  in  less  than  three  hours. 

Exerting,  as  alcohol  does,  its  pernicious  influence  upon  the  brain  and 
nervous  system,  it  produces  a  variety  of  mental  disorders  of  an  insane 
nature,  of  which  seven  different  forms  may  be  recognised : — (1)  There  is  tem- 
porary mental  derangement,  or  simple  intoxication,  induced  in  anyone  by 
the  absorption  of  alcohol.  (2)  Mania  a  potu,  in  which  the  individual  thus 
affected  differs  from  the  man  who  is  simply  intoxicated,  in  so  far  as  he  is 
the  subject  of  violent  mania.  He  cannot  control  his  acts.  In  this  state 
he  is  more  or  less  forgetful  of  the  circumstances  that  have  occurred,  and  is 
apt  to  be  violent  and  destructive  without  necessarily  being  in  a  passion.  For 
the  time  being  the  individual  is  so  "  possessed,"  that  he  is  driven  to  the  com- 
mission of  acts,  it  may  be  of  homicidal  violence,  that  are  quite  beyond  his 
control,  and  subsequently  beyond  his  memory.  In  a  few  minutes  his  out- 
burst of  maniacal  excitement  may  be  over,  or  it  may  continue  for  hours, 
being  occasionally  broken  by  periods  of  quiescence,  during  which  the  pulse 
which  was  strong  and  full,  resumes  its  normal  character — the  temperature 
throughout  never  having  risen.  Since  many  people  who  are  in  the  habit  of 
getting  drunk  never  pass  into  this  maniacal  state,  and  since  it  occurs 
regularly  in  those  of  a  peculiar  nervous  temperament,  even  after  taking 
what  to  others  would  be  a  very  moderate  dose  of  alcohol,  mania  a  potu 
would  seem  to  depend  rather  upon  a  peculiar  diathesis,  or  some  congenital 
instability  of  the  nervous  system,  whereby  it  becomes  easily  excited  and 
unduly  responsive  to  small  quantities  of  alcohol,  than  upon  any  excess  of 
drink  taken.  A  morbid  nervous  substratum,  hereditarily  acquired,  under- 
lies this  condition,  for  the  individual  is  predisposed  to  epilepsy  or  to 
some  other  form  of  nervous  disorder.  (3)  In  the  third  form,  or  delirium 
tremens,  the  individual  is  insane,  and  is  the  subject  of  delusions  and  illusions. 
He  may  not  have  been  drinking  immediately  before  his  outburst  of  delirium. 
The  attack  is  therefore  not  traceable  to  a  particular  draught  of  alcohol, 


600       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

although  it  may  arise  after  a  single  debauch.  It  occurs  in  people  who  are 
specially  predisposed,  and  who  are  habitually  taking  spirituous  liquors  to 
excess.  What  that  peculiarity  of  bodily  or  nervous  constitution  is  that 
predisposes  to  it,  it  is  difficult  to  say.  Some  have  maintained  that  sudden 
abstinence  is  a  cause,  but  while  there  is  no  proof  of  this,  there  is  sufficient 
evidence  that  physical  and  mental  conditions  which  lower  the  vitality  of 
the  nervous  system,  such  as  shock  from  injury  or  surgical  operation,  exposure 
to  cold  and  overwork,  precipitate  an  attack  of  delirium  tremens.  For  several 
days  before  the  outburst,  friends  may  have  noticed  that  the  patient  was  not 
quite  well,  that  he  was  off  his  food,  fidgety,  and  sleepless,  and,  when  seen  by 
his  medical  attendant  at  this  stage,there  is  a  furred  tongue,the  skin  is  bedewed 
with  a  cold  clammy  perspiration,  and  the  person  looks  jaded  and  is  tremulous. 
In  the  midst  of  this,  he  passes,  without  further  warning,  into  a  condition  of 
great  excitement.  In  his  delirium  he  may  perpetrate  acts  of  violence  upon 
himself  or  others,  in  his  attempts  to  escape  from  the  ocular  illusions  and 
auditory  hallucinations  of  which  he  is  the  unhappy  victim.  Flushed  in  the 
face  and  perspiring  freely,  with  a  rapid,  full,  but  soft  pulse,  a  thickly-coated 
tongue,  and  sleepless,  he  is  with  difficulty  restrained.  In  his  delirious 
moments  he  keeps  muttering  about  business  matters,  or  answers  loudly  to 
unreal  voices ;  he  may  escape  the  vigilance  of  those  who  are  nursing  him,  or 
he  may  overcome  them  by  his  superior  force,  and  in  his  delirium  leap  from 
a  window,  or  in  a  state  of  terror  commit  self-destruction.  The  fury  may 
continue  for  two  or  three  days,  when  it  is  succeeded  by  a  state  of  great 
asthenia,  in  which  the  patient  lies  mumbling  to  himself,  picking  at  the  bed- 
clothes, occasionally  returning  answers  to  unheard  questions,  carrying  on 
conversations  or  talking  incoherently,  but  with  a  voice  low  and  indicative 
of  great  prostration,  the  tongue  brown  and  dry,  the  pulse  small  and  rapid. 
Sleeplessness  continues,  and  the  organic  functions  are  all  more  or  less 
deranged.  There  may  be  retention  of  urine,  requiring  the  use  of  the 
catheter,  and  the  urine  when  drawn  off  may  be  albuminous.  The  delirium 
of  the  earlier  stage  is  now  replaced  by  one  of  great  exhaustion,  or  it  is 
paroxysmal ;  and  although  it  is  still  violent,  its  spells  are  of  shorter  duration, 
and  are  accompanied  by  increasing  prostration,  which  rapidly  leads  to  death. 
(4)  Chronic  alcoholism,  in  which,  while  the  individual  is  seldom  or  never 
quite  drunk,  he  is,  on  the  other  hand,  never  perfectly  sober.  His  nervous 
system,  too  long  flushed  with  alcohol,  breaks  down,  and  the  man  becomes 
either  imbecile  or  an  epileptic.  Convulsive  seizures  may  alternate  with 
paroxysms  of  mania,  in  which  the  individual,  who  is  quite  insane,  may 
perpetrate  deeds  of  criminal  violence,  of  the  nature  of  which  he  is  per- 
fectly unconscious,  and  in  regard  to  which  his  memory  is  a  complete  blank. 
Occasionally  seizures  of  an  ordinary  epileptic  character  occur  without  any 
maniacal  phenomena.  These  are  usually  traceable  to  alcoholic  indulgence, 
and  are  causally  connected  with  it,  for  they  disappear  during  total  abstinence, 
and  return  with  drinking.  When  an  epileptic  fit  occurs  for  the  first 
time  in  an  individual  who  is  addicted  to  alcohol,  it  is  one  of  the  earliest 
indications  of  the  brain  giving  way,  and  is  a  symptom  never  to  be  dis- 
regarded, nor  thought  lightly  of  by  the  medical  attendant.  Underneath 
chronic  alcoholism  there  is  generally  in  operation  an  inherited  predis- 
position to  some  form  of  nervous  disease,  which  shows  itself  in  a  tendency 
to  excessive  drinking,  suicide,  epilepsy,  or  some  other  form  of  nervous 
disorder.  (5)  Habitual  drunkenness  constitutes  the  fifth  variety.  Although 
this  is  a  condition  practically  speaking  uncontrollable,  it  is  yet  within 
the  conceivable  control  of  the  will.     G-airdner,  in  his  Class  Lectures  on 


ALCOHOLIC  POISONING.  60 1 

"Drink  Madness,"  and  whose  classification  I  have  adopted,  thus  speaks 
of  habitual  drunkenness  as  a  condition  in  which  "  the  moral  nature  is 
not  yet  completely  sapped :  the  man  is  not  utterly  shameless  in  the 
indulgence  of  his  desire :  he  may  know  and  admit  the  folly  of  his  course, 
but  the  power  of  the  will  is  so  weakened,  and  the  taste  so  depraved,  that 
in  the  work  of  life  he  is  sure  to  go  wrong."  (6)  Dipsomania,  in  which  the 
individual  is  so  much  under  the  domination  of  appetite,  that  no  considera- 
tion can  control  him,  if  by  any  possibility  he  can  gratify  it.  During  the 
weeks  or  months  he  is  sober  he  knows  that  a  time  is  coming  when  the 
craving  for  alcohol  will  be  so  great  that,  short  of  bodily  constraint,  nothing 
will  prevent  him  drinking.  In  this  and  in  the  condition  last  described,  the 
individual  is  unquestionably  insane,  and  yet,  because  the  mental  phenomena 
depend  upon  a  definite  and  recognisable  material  having  been  taken,  namely, 
alcohol,  the  law  is  not  disposed  to  recognise  these  as  insanity.  It  holds  that 
the  man  is  just  as  responsible  for  his  acts  as  if  he  were  sober,  although  the 
same  condition  arising  from  unknown  causes  would  certainly  lead  the 
individual  to  be  regarded  as  insane,  and  therefore  irresponsible.  The  law 
assumes  that,  as  the  individual  voluntarily  took  that  which  made  him 
insane,  he  is  responsible  for  the  mental  condition  which  it  has  created, 
and  it  is  the  knowledge  of  this  fact  which  obliges  medical  men  to  act 
with  extreme  caution  in  cases  of  drink  madness,  particularly  delirium 
tremens,  in  which  the  civil  rights  and  personal  liberty  of  the  individual 
cannot  be  interfered  with,  except  at  the  greatest  risk  to  those  who  thus  seek 
to  interpose.  (7)  General  paralysis,  imbecility,  and  several  neuroses, — for 
these  and  other  large  questions  bearing  upon  alcoholic  insanity  and  legal 
responsibility,  special  text-books,  however,  must  be  consulted. 

As  a  consequence  of  prolonged  indulgence  in  alcohol,  the  central 
nervous  system  suffers,  but  the  peripheral  nerves  do  not  always  escape. 
Alcoholic  neuritis  is  a  well-defined  clinical  condition,  dependent  upon 
a  recognisable  pathological  lesion.  Men  are  more  the  subjects  of 
delirium  tremens  than  women,  but  women  are  more  liable  to  alcoholic 
peripheral  neuritis,  an  affection  which  attacks  the  legs  oftener  than  the 
arms.  Occasionally  lethargy,  disinclination  for  muscular  exertion,  and 
an  increasing  difficulty  of  walking,  foretell  the  approach  of  the  paralysis ; 
while  in  other  patients  there  are,  as  premonitory  symptoms,  burning  pains 
in  the  soles  of  the  feet,  painful  cramps  in  the  calves,  the  muscles  of  which 
are  extremely  tender  to  the  grasp,  absent  knee-jerks,  and  exaggerated 
cutaneous  reflexes.  Or  there  is  patchy  anaesthesia,  flabby  muscles,  cold 
extremities  and  glistening  skin,  pain  along  the  course  of  the  nerves,  and 
close  upon  these  comes  paralysis,  e.g.  double  "  ankle-drop  "  or  "  wrist-drop." 
Sometimes  paralysis  develops  in  the  feet  and  legs  simultaneously  without 
any  prodromata.  The  muscles  rapidly  waste,  and  cease  to  react  to  faradism. 
The  urine  may  or  may  not  contain  albumin.  In  addition  to  organic  changes 
in  the  nervous  system,  there  may  be  observed  in  alcoholic  patients  certain 
morbid  phenomena  which  are  due  to  functional  derangement  of  the  nervous 
system,  rather  than  to  the  existence  of  any  altered  structure,  since  they 
rapidly  disappear  under  enforced  abstinence,  medicinal  treatment,  and  rest. 
Alcoholic  ataxia,  or  pseudo-tabes,  belongs  to  this  class,  and  is  sufficiently 
common  to  be  now  recognised  as  a  distinct  entity.  Muscular  tremor, 
particularly  in  the  morning,  is  perhaps  one  of  the  earliest  signs  of  chronic 
tippling.  In  a  patient  whom  I  saw  recently,  there  were  several  of  the 
signs  of  disseminated  sclerosis,  e.g.  nystagmus,  tremor,  and  altered  speech, 
but  the  circumstances  which  enabled  me  to  differentiate  the  illness  from 


602        DISEASES  CA  USED  BY  CHEMICAL  SUBSTANCES. 

the  classical  disease  which  it  simulated,  were  the  history  of  the  case,  the 
extreme  rapidity  with  which  the  symptoms  had  developed,  and  subsequently 
their  rapid  disappearance  under  treatment.  In  another  patient,  symptoms 
strongly  suggestive  of  general  paralysis  presented  themselves,  but  the  youth- 
ful age  of  the  patient,  his  well  regulated  movements,  and  the  disappear- 
ance of  the  symptoms  under  total  abstinence,  demonstrated  their  func- 
tional character.  Among  the  other  effects  of  chronic  alcoholism  may  be 
mentioned  general  or  circumscribed  oedema,  also  thrombosis  of  veins  and 
albuminuria,  which  in  time  is  followed  by  signs  of  interstitial  nephritis. 
The  heart  too  is  apt  to  become  dilated  and  the  myocardium  softened. 

In  the  case  of  an  acute  illness  in  a  child,  or  for  the  weak  digestion  of 
enfeebled  infants,  small  doses  of  brandy  may  be  temporarily  beneficial. 
Children  bear  very  large  doses  of  alcohol  badly,  they  quickly  become 
comatose  and  die.  A  few  ounces  of  pure  whisky  may  throw  a  child 
of  tender  years  into  a  state  of  stupor,  in  which  he  remains  for  two 
or  three  days,  and  dies  without  regaining  consciousness ;  or  the  drowsi- 
ness, whilst  persisting  for  days,  is  interrupted.  There  is  spastic  con- 
traction of  the  limbs,  unilateral  or  general  convulsions,  slight  optic 
neuritis,  with  a  normal  temperature.  In  other  cases,  all  the  extremities 
are  paralysed.  The  coma  and  convulsions  thus  induced  in  children 
closely  resemble  those  observed  in  adults  who  are  chronic  drinkers, 
and  in  whom  meningitis  has  developed.  In  the  case  of  children,  as  in 
adults,  the  administration  of  alcohol  for  a  lengthened  period  by  parents, 
given  with  the  view  of  strengthening  them,  is  followed  by  gastric  derange- 
ment, chronic  intestinal  catarrh,  defective  development,  epileptic  seizures, 
and  subsequently  by  pathological  changes  in  the  liver,  which  ultimately 
lead  to  cirrhosis  of  that  organ.  Women  who  have  children  at  the  breast 
should  be  extremely  abstemious  as  regards  alcohol,  for  experience  has  shown 
that  the  intemperate  use  of  spirits  by  mothers,  when  nursing,  has  caused 
their  infants  to  become  excited,  and  induced  a  train  of  symptoms  not 
unlike  those  observed  in  meningitis. 

There  is  an  impression  in  the  public  mind  that  alcohol,  in  some  way  or 
another,  prevents  an  individual  catching  infectious  disease.  It  used  to  be 
stated,  too,  that  if  a  man  took  spirits,  he  was  able  to  do  more  muscular  work, 
and  that  he  endured  cold  better.  The  experience  of  our  military 
authorities  contradicts  the  second  assertion,  and  that  of  Arctic  explorers 
the  third.  In  my  Goulstonian  lectures  on  lead  poisoning,  I  confirm,  by 
experiments  upon  animals,  what  clinical  experience  had  suggested,  so  far 
as  this  form  of  industrial  poisoning  is  concerned,  namely,  that  lead  workers 
who  indulge  in  alcohol  become  a  readier  prey  to  plumbism  than  their  more 
temperate  mates.  It  is  of  the  utmost  importance  that  a  definite  opinion 
should,  as  far  as  possible,  be  expressed  upon  the  question  of  whether  alcohol 
has  or  has  not  any  influence  in  preventing  infectious  disease.  Abbott  gives 
the  details  of  numerous  experiments  which  he  carefully  carried  out  upon 
rabbits,  with  the  view  of  ascertaining  how  far  alcohol  protects  animals 
against,  or  precipitates  them  into,  infectious  illnesses.  The  question,  briefly 
put,  is  this  :  Is  the  normal  vital  resistance  of  an  individual  to  infection  by 
the  common  pathogenic  bacteria  favourably  influenced  by  pure  alcohol, 
and  if  so,  does  the  fact  hold  good  for  beer,  wines,  etc.  ?  The  experiments 
had  reference  principally  to  resistance  to  such  organisms  as  the  pyogenic 
cocci,  the  Streptococcus  pyogenes  erysipelatis,  the  Staphylococcus  pyogenes 
aureus,  and  the  Bacillus  coli  communis.  Diluted  alcohol  was  administered 
by  intravenous  injection ;  it  was  carefully  measured,  and  administered  in 


ALCOHOLIC  POISONING.  603 

quantities  bearing  a  distinct  relation  to  the  weight  of  the  animal  and  the 
symptoms  of  intoxication  produced.  Some  of  the  animals  were  scarcely 
disturbed  even  by  large  doses,  while  in  others,  at  the  post-mortem  examina- 
tion, there  were  found  such  visible  evidences  of  the  effects  of  alcohol  as 
acute  gastritis,  e.g.  erosion  and  inflammation  of  the  mucous  membrane. 
Control  experiments  were  made  with  animals  to  whom  no  alcohol  was 
administered,  the  inoculations  being  the  same  in  both.  Abbott  took  six 
rabbits  that  were  receiving  alcohol  daily  in  sufficient  quantities  to  become 
intoxicated,  and  he  inoculated  them  with  bouillon  cultures  of  the  Streptococcus 
pyogenes,  obtained  from  a  phlegmonous  inflammation  in  the  human  subject ; 
at  the  same  time  he  similarly  inoculated  five  rabbits  to  whom  no  alcohol 
had  been  given.  All  the  six  rabbits  died  after  losing  weight,  and  they 
exhibited  lesions  referable  to  the  inoculation  (one  of  the  animals  showing, 
at  the  same  time,  in  its  liver  the  distinct  effects  of  alcohol),  while  of  the  five 
inoculated  non-alcoholic  animals,  only  one  died.  Subsequently,  he  inocu- 
lated eighteen  rabbits  with  suspensions  of  Streptococcus  pyogenes.  Of 
nine  to  whom  alcohol  had  been  administered,  seven  died  with  suppurative 
lesions ;  and  as  regards  the  other  nine,  to  whom  no  alcohol  had  been  given, 
no  effect  followed  until  the  fifteenth  day,  when  five  died.  His  results 
obtained  from  suspensions  of  the  Bacillus  coli  communis  are  not  less 
interesting.  They  prove  that,  instead  of  fairly  large  doses  of  alcohol 
increasing  the  vital  resistance  to  infectious  disease,  such  tend  not  only 
to  lower  this  resistance,  hut  to  increase  the  severity  of  the  illness  when 
caught.  This  opinion,  arrived  at  as  the  result  of  experimentation  upon 
animals,  is  quite  in  keeping  with  our  clinical  experience  of  how  badly 
borne  pneumonia,  erysipelas,  and  other  infectious  diseases  are  by  men  who 
have  been  in  the  habit  of  consuming  large  quantities  of  alcohol  daily. 

Nor  is  there  any  truth  in  the  opinion  held  by  the  laity,  that  the  use  of 
alcohol  protects  the  individual  against  tuberculous  disease.  I  do  not  refer 
to  such  a  restricted  employment  of  alcohol  as  a  glass  of  beer  or  stout  or  a 
little  wine  at  dinner  time.  That  may  be  helpful  to  the  individual.  It  is 
to  the  mistaken  opinion  that  where  there  is  a  family  predisposition  to  the 
disease,  it  is  necessary  to  be  somewhat  more  indulgent.  In  my  experience 
of  young  men  with  a  hereditary  tendency  to  phthisis,  alcohol  has,  by  the 
late  hours  which  it  encourages,  and  the  careless  and  irregular  habits  that 
it  fosters,  frequently  precipitated  the  individual  into  active  tuberculous 
disease,  which  abstinence  and  more  careful  living  would  assuredly  have 
prevented.  It  indirectly  favours  the  development  of  tuberculous  disease. 
Pulmonary  tuberculosis  was  found  by  Dickinson  to  be  more  frequent 
in  drinkers  than  in  ordinary  people  in  the  proportion  of-  three  to  two. 
Eolleston,  quoting  H.  Mackenzie,  states  that  in  sixty-seven  cases  of 
pulmonary  tuberculosis  occurring  in  drinkers,  a  family  history  of  tubercle 
was  only  found  in  ten,  whereas  it  is  found  in  about  30  per  cent,  of  the 
ordinary  cases.  The  frequent  association  of  pulmonary  tuberculosis  with 
alcoholic  peripheral  neuritis,  and  its  presence,  too,  in  nearly  one-third  of  the 
cases  of  cirrhosis  of  the  liver,  are  circumstances  which  show  that  under  the 
debilitating  influence  of  alcohol  vital  resistance  is  reduced,  ordinary 
pulmonary  catarrhs  are  not  so  quickly  thrown  off,  and  thus  the  bacillus 
of  tubercle  gains  an  easier  entrance. 

Diagnosis. — Now  and  again  it  has  happened  that  an  individual, 
found  helpless  and  unconscious  in  the  streets,  and  believed  by  the 
police  to  be  drunk,  has  been  taken  to  the  lock-up  and  placed  in  the  cells 
overnight,  where  he  is  found  dead  next  morning.     This  has  happened  so 


6o4        DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

often,  that  hi  our  large  towns  the  casualty  surgeon  is  more  frequently 
called  in  than  formerly  to  make  a  diagnosis  in  doubtful  cases,  for  cerebral 
haemorrhage,  fractured  skull,  uraemic,  diabetic,  and  epileptic  coma  have 
to  be  differentiated  from  acute  alcoholic  poisoning.  The  police  cells  are 
now  in  many  cities  warmed,  so  that  death  from  lowering  of  the  body 
temperature,  which  is  one  of  the  consequences  of  alcoholism,  is  less  likely 
to  occur,  besides  the  inmates  are  usually  visited  at  short  intervals.  A 
diagnosis  is  too  frequently  made  simply  from  the  alcoholic  odour  which 
hangs  about  an  individual,  but  this  is  not  enough ;  neither  must  a  stagger- 
ing gait,  inability  to  stand,  nor  the  use  of  obscene  and  violent  language, 
be  regarded  as  absolute  proofs  of  drunkenness,  for  these  may  all  be 
exhibited  by  a  patient  suffering  from  cerebral  haemorrhage.  The  urine 
should  in  all  doubtful  cases  be  examined  for  albumin  and  sugar,  and  the 
vomit  for  alcohol.  As  alcohol  is  eliminated  by  the  kidneys,  Anstie  taught 
that  an  examination  of  the  urine  for  alcohol  might  be  a  useful  help,  but 
although  one  drop  of  alcoholic  urine  will  give,  when  added  to  15  minims  of 
chromic  acid  solution  (1  in  300),  a  bright  emerald-green  colour,  this  cannot 
be  regarded  as  absolute  proof  that  a  poisonous  dose  of  alcohol  has  been  taken. 
When  taken  in  excess,  alcohol  is  eliminated  by  the  kidneys.  Another  test 
for  alcohol  is  the  production  of  iodoform.  Heat  the  suspected  liquid  in  a 
test  tube  with  iodine  and  caustic  potash,  and  if  alcohol  is  present  yellow 
crystals  of  iodoform  will  appear.  So  delicate  is  this  test,  that  it  will  detect 
alcohol  in  the  proportion  of  1  in  10,000.  Signs  of  fracture  of  the  skull 
with  depression  of  bone  and  of  cerebral  haemorrhage  should  be  carefully 
sought  for.  Coma  may  be  present  in  cerebral  haemorrhage,  and  if  the 
bleeding  has  occurred  into  the  pons  the  pupils  may  be  pin-point.  I 
agree  with  Norman  Kerr  that  "  the  only  safe  rule  in  such  obscure  cases 
is  to  treat  the  patient  as  suffering  from  an  underlying  and  grave  ailment, 
till  the  acute  alcoholic  symptoms  have  had  time  to  disappear." 

The  diagnosis  of  mania  a  potu  rests  upon  the  history  of  recent 
drinking.  Delirium  tremens,  on  the  other  hand,  may  develop  in  people  who 
have  not  been  immediately  drinking.  ~No  alcohol  may  have  been  taken  for 
several  days,  and  yet  under  the  influence  of  an  injury,  exposure  to  cold, 
etc.,  an  individual  of  intemperate  habits  may  develop  delirium  tremens. 
To  distinguish  between  alcoholic  delirium  and  the  excitement  and  wander- 
ing observed  in  pneiunonia  and  specific  fevers,  the  absence  of  rise  of 
temperature  and  of  dulness  on  percussion  over  the  lungs  would  be  important. 
But  as  a  patient  with  pneumonia  may  also  be  the  subject  of  delirium 
tremens,  it  is  well  to  remember  that  acute  delirium  may  last  through  the 
early  part  of  the  illness,  and  while  it  obviously  increases  the  gravity  of  the 
illness,  it  does  not  necessarily  follow  that  the  case  is  absolutely  hopeless. 

The  diagnosis  of  alcoholic  neuritis  is  not  always  easy,  for  it  frequently 
occurs  in  women  of  whose  habits  it  is  almost  impossible  to  obtain  an 
accurate  history,  even  from  their  husbands,  who  too  often  are  ignorant  of 
the  vice  that  is  secretly  indulged  in.  Alcoholic  "  foot-drop  "  and  "  wrist- 
drop "  are  distinguished  from  lead  poisoning  by  the  absence  of  a  blue  line 
on  the  gums,  also  by  the  history  of  painful  sensations  in  the  limbs, 
hyperaesthesia  of  skin,  mental  irritability,  or  enfeeblement.  It  is  the 
presence  of  such  sensory  symptoms,  and  the  fact  of  the  illness  being  more 
slowly  developed,  that  enable  us  to  distinguish  alcoholic  neuritis  from  the 
acute  spinal  paralysis  of  Landry. 

Paralysis  due  to  alcoholic  peripheral  neuritis  may  persist  for  a  long 
time  and  resist  treatment,  yet  even  apparently  hopeless  cases  may  in  time 


ALCOHOLIC  FOISONING.  605 

recover.  For  fully  twelve  months  a  male  alcoholic  paralytic  occupied 
one  of  my  beds  in  the  Newcastle  Infirmary.  There  was  double  ankle- 
drop,  pointing  of  the  toes,  very  marked  atrophy  of  the  legs,  loss  of  knee- 
jerk,  and  extreme  emaciation  generally.  The  patient  could  neither  stand 
nor  walk,  but  by  means  of  treatment,  medicinal,  electrical,  and  massage 
perseveringly  followed,  the  disease  was  overcome,  so  that  a  little  over  a 
year  after  his  admission  he  walked  out  of  the  hospital.  The  extreme 
emaciation  of  the  limbs  in  alcoholic  neuritis  suggests  progressive  muscular 
atrophy,  but  in  progressive  muscular  atrophy  there  is  no  sensory  dis- 
turbance ;  besides,  it  is  usually  slower  in  its  development,  and  the  disease 
tends  to  affect  the  muscles  of  the  hand  and  to  create  the  deformity  known  as 
"  main  en  griffe."  From  acute  anterior  poliomyelitis  it  is  distinguished  by 
the  paralysis  being  in  this  disease  more  complete,  by  sensory  symptoms 
being  absent,  and  by  groups  of  muscles  being  simultaneously  attacked,  also 
by  the  fact  of  tenderness  on  pressure  being  more  noticeable  in  alcoholic 
peripheral  neuritis.  Hysterical  paralysis  may  be  mistaken  for  alcoholic, 
but  the  loss  of  power,  which  in  alcoholism  is  usually  bilateral,  is,  along 
with  distinct  loss  of  sensation,  unilateral  in  hysteria. 

Much  of  the  chronic  invalidism  seen  in  women  who  compxain  of 
frequent  sensations  of  faintness,  is  the  outcome  of  indulgence  in  alcohol. 
It  is  always  a  suspicious  circumstance,  where  women  lie  in  bed  the  greater 
part  of  the  day,  neglectful  of  domestic  duties,  and  in  whom  no  signs  of 
real  illness  can  be  detected. 

Prognosis. — With  the  exception  of  those  patients  whose  coma  is 
profound,  or  in  cases  where  the  severer  forms  of  delirium  tremens  are 
ushered  in  by  convulsions,  and  accompanied  by  a  rise  of  temperature,  and 
where  excitement  is  accompanied  by  sleeplessness  and  inability  to  take 
food,  where  there  are  also  albuminuria,  rapid  pulse,  weak  heart  sounds, 
and  signs  of  great  prostration,  the  prognosis  is  favourable.  Norman  Kerr 
considers  the  recovery  to  be  90  per  cent.  The  prognosis  of  uncom- 
plicated alcoholic  peripheral  neuritis  is  also  favourable,  but  in  this  and 
all  other  forms  of  alcoholism,  it  is  a  necessary  part  of  the  treatment  that 
the  use  of  spirits  should  be  absolutely  forbidden. 

Treatment. — In  very  slight  cases  of  delirium  tremens,  beyond  with- 
holding alcohol,  the  treatment  is  almost  nil,  for  such  cases  tend  to 
spontaneous  cure.  The  treatment  of  the  severer  cases  resolves  itself  into 
quieting  the  delirium,  improving  elimination  and  supporting  strength.  As 
the  symptoms  are  due  to  a  toxaemia,  drugs  given  to  induce  sleep  and 
quieten  the  nervous  system  must  be  administered  carefully.  Opium  and 
morphine,  in  order  to  accomplish  this,  have  to  be  given  in  rather  large  doses, 
and  there  is  considerable  risk  in  pushing  them.  This  remark  applies  to  all 
narcotics,  particularly  if  the  emunctories  are  inactive,  and  there  is  albumin 
in  the  urine.  A  hypodermic  injection  of  hyoscin,  y^o^n  or  "rod^n  °f  a 
grain,  may  produce  sleep,  where  morphia  only  causes  excitement,  but  its 
effects  must  be  watched.  The  application  of  cold  to  the  head,  a  mixture 
of  bromide  of  potassium,  40  grs.,  and  of  chloral,  20  grs.,  may  be  given,  and 
repeated  in  an  hour  or  two  if  necessary,  or  a  mixture  of  potassium  bromide, 
20  grs.,  and  tincture  of  hyoscyamus,  \  oz.,  with  ammonia  and  tinct. 
lupuli,  or  of  pot.  brom.  and  tinct.  digitalis,  is  often  serviceable.  Other 
hypnotics,  such  as  paraldehyde,  urethan,  sulphonal,  or  trional,  may  be 
given.  All  these  drugs  give  best  results  when  preceded  by  a  free  calomel 
purge.  The  administration  of  chloroform  has  been  recommended,  but  its 
use  is  attended  with  danger.      I   have  known  it  cause  death.     For  the 


606       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

acute  delirium  of  a  strong  and  well-built  alcoholic  subject,  circumstances 
may  be  such,  owing  to  the  absence  of  sufficient  personal  help,  that  physical 
restraint  of  the  individual  may  be  necessary,  e.g.  placing  him  in  a  padded 
room,  or  the  use  of  the  strait-jacket.  The  employment  of  the  strait- 
jacket,  however,  must  be  carefully  watched.  I  have  never  seen  any  bad 
effects  from  the  strait-jacket,  but  I  am  extremely  careful  to  apply  it  only 
in  uncomplicated  cases,  and  then  but  for  a  very  short  time.  Should  an 
alcoholic  patient  who  is  suffering  from  delirium  tremens  develop  in 
addition  a  pneumonia,  and  which  a  rise  of  temperature  would  suggest,  the 
strait-jacket,  if  applied,  would,  by  embarrassing  the  movements  of  the  chest 
wall  and  pressing  upon  the  false  ribs,  aggravate  the  pulmonary  congestion, 
by  forcing  the  respiration  to  become  abdominal.  The  strength  of  the 
patient  under  all  circumstances  must  be  maintained,  by  means  of  strong 
soups,  coffee,  and  milk,  eggs  beaten  up  with  milk,  etc.  We  are  often 
asked  should  stimulants  be  given  to  alcoholic  patients  when  there  is 
evidence  of  the  heart  flagging  and  the  pulse  becoming  weak  ?  Friends 
of  a  patient  will  press  this  question  upon  the  medical  attendant,  in 
the  belief  that  it  is  in  consequence  of  the  sudden  withdrawal  of  the 
usual  stimulant  to  which  the  individual  has  been  accustomed,  that 
part  of  the  illness  is  due.  As  the  symptoms  are  consequent  upon  alcohol 
having  poisoned  the  blood  and  deranged  the  nerve  centres,  we  fail  to  see, 
on  the  theory  of  an  existing  toxasraia,  how  the  withholding  of  the  poison 
that  created  the  illness  can  be  the  cause  of  the  cerebral  excitement. 
So  far  as  prostration  is  concerned,  usually  this  can  be  just  as  well 
met  by  stimulants  other  than  alcoholic.  I  cannot  remember  a  patient 
suffering  from  delirium  tremens  to  whom  I  have  been  obliged  to  ad- 
minister alcohol,  but  I  would  not  refuse  it  if  circumstances  demanded 
it.  Cardiac  failure  may  be  treated  by  hypodermic  injections  of  spartein 
or  of  caffeine.  It  is  always  desirable  to  get  the  tongue  cleaned,  the 
emunctories  kept  active,  and  a  taste  for  food  established.  When  the 
patient  begins  to  improve,  strychnine  nitrate  is  a  useful  tonic.  Under 
its  administration  the  craving  for  alcohol  diminishes,  so  that  in  a  few 
days  it  is  completely  gone.  Under  the  combined  influence,  therefore, 
of  abstinence  from  alcohol  on  the  one  hand,  and  the  administration  of 
strychnine  on  the  other,  the  patient  is  soon  restored  to  health;  but, 
unfortunately,  within  the  next  few  months  there  is  perhaps  a  relapse,  and 
it  may  be  another  attack  of  delirium  tremens.  In  all  cases  it  is  necessary, 
where  the  delirium  endures,  that  the  patient  should  not  be  left  alone,  for, 
in  the  absence  of  the  nurse  or  attendant,  he  may  throw  himself  from  a 
window,  or  resort  to  some  other  method  of  self-destruction.  It  is  our  duty 
to  protect  the  individual  against  himself,  as  well  as  to  prevent  him  from 
injuring  others.  It  is  during  the  first  three  or  four  days  of  the  delirium 
that  these  accidents  are  most  likely  to  occur. 

It  is  all  but  impossible  to  prevent  relapses  on  the  part  of  alcoholics. 
The  administration  of  strychnine,  cinchona  rubra,  and  the  "gold"  cure  have 
each  their  advocates,  but  experience  has  shown  that,  while  such  patients 
can  be  restored  to  temporary  health,  their  weakened  will  does  not  enable 
them  to  rise  above  temptation.  Safety  for  them  alone  lies  in  total 
abstinence.  An  active  out-door  life,  and  removal  of  the  individual  from 
all  causes  of  worry  and  from  his  boon-companions,  temporary  voluntary 
retirement  to  a  retreat  or  to  a  home  for  inebriates,  are  recommendations 
the  utility  of  which  must  be  gauged  by  the  particular  case  in  question. 

The  chloride  of  gold  just  alluded  to  is  administered  hypodermically, 


MEAT  OR  PTOMAINE  POISONING.  607 

y^th  of  a  grain  in  10  minims  of  water,  thrice  daily.  It  is  regarded  by 
some  physicians  as  one  of  the  best  therapeutic  agents  in  the  treatment 
of  chronic  alcoholism,  its  action  being  similar  to  that  of  phosphorus  and 
strychnine  upon  the  brain  and  spinal  cord.  Patients  have  blamed  the 
"  gold  "  cure  for  a  subsequent  temporary  impotency  that  is  said  to  have 
arisen,  but  experience  does  not  support  this  statement.  Occasionally  the 
arms  swell  in  consequence  of  the  repeated  hypodermic  injections,  but  this 
readily  yields  to  rest  and  the  application  of  a  lead  lotion. 


MEAT  OE  PTOMAINE  POISONING. 

History. — For  centuries  men  must  have  known  that  the  ingestion  of 
putrid  food  might  be  followed  by  serious  consequences,  but  it  was  von 
Halier  who,  during  the  last  century,  first  narrated  how  death  followed 
the  injection  of  an  aqueous  extract  of  putrescent  meat  into  the  veins  of 
animals.  In  1853,  Stich  showed  that  the  administration  of  decomposing  food 
caused  intestinal  catarrh,  choleraic  stools,  staggering  gait,  convulsions,  and 
death,  without  any  lesion  being  found  at  the  autopsy.  Panum,  three  years 
later,  determined  the  chemical  nature  of  the  poisons  in  putrefying  food,  and 
demonstrated  their  action  upon  the  living  body.  Since  then  many  investi- 
gators have  been  at  work  trying  to  solve  the  problems ;  but,  as  it  was 
Selnii  who  first  suggested  the  name  ptomaine  for  the  poison,  so  did  he  give 
an  impetus  to  the  study  of  the  chemical  processes  involved  in  putrefaction. 
Selmi,  however,  did  not  succeed  in  isolating  any  single  putrefactive  alkaloid. 
This  was  reserved  for  Nencki  in  1876,  and  it  is  to  him  we  are  indebted 
for  the  first  chemical  formula  of  a  ptomaine.  Brieger  has  isolated  and 
determined  the  composition  of  many  of  these  alkaloids,  and  has  contri- 
buted largely  to  the  literature  of  the  subject.  To  the  solution  of  the 
many  chemical  and  bacteriological  problems,  which  this  form  of  poison- 
ing raises,  men  like  Vaughan,  Novy,  Hankin,  Sidney  Martin,  Stevenson, 
Kanthack,  Brouardel,  Bouchard,  and  Gautier  have  devoted  much  of  their 
time;  but,  in  spite  of  the  excellent  work  which  these  pathologists  have 
accomplished,  the  subject  of  ptomaine  poisoning  remains  one  of  consider- 
able mystery. 

Etiology. — The  subject  of  meat  poisoning  is  still  one  of  such  consider- 
able obscurity  and  uncertainty,  that  it  is  impossible  to  speak  dogmatically 
upon  it.  In  the  incriminated  article  of  food  there  are  frequently  found 
micro-organisms  and  complex  chemical  compounds.  These  chemical 
bodies,  since  they  are  capable  of  combining  with  acids,  resemble  in- 
organic and  vegetable  bases.  To  them  Selmi,  an  Italian  toxicologist, 
gave  the  name  of  ptomaines,  from  the  Greek  word  irrafia,  a  cadaver. 
Ptomaines  are  chemical  bodies,  basic  in  character,  which  develop  in 
organic  matter  through  the  activity  of  bacteria,  and  since  this  is  generally 
undergoing  decomposition  these  products  are  on  that  account  sometimes 
called  putrefactive  alkaloids.  Usually  formed  during  the  early  stages 
of  decomposition,  they  are  regarded  by  Vaughan  and  Novy  as  "  transition 
products  in  the  process  of  putrefaction,  temporary  forms  through  which 
matter  passes,  while  it  is  being  transformed  by  the  activity  of  bacterial  life 
from  the  organic  to  the  inorganic  state."  Like  vegetable  alkaloids,  they 
all  contain  nitrogen,  but  not  all  of  them  oxygen.     The  kind  of  ptomaine 


608        DISEASES  CA  USED  BY  CHEMICAL  SUBSTANCES. 

formed  during  putrefaction  must  necessarily  depend  upon  the  particular 
bacterium  present,  the  nature  of  the  organic  matter  that  is  decomposing, 
and  the  conditions  under  which  putrefaction  is  taking  place.  Bacteria 
were  described  by  Pasteur  as  aerobic  or  anaerobic,  according  as  they  grew 
best  in  the  comparative  presence  or  absence  of  air.  Many  micro-organisms 
flourish  best  when  air  is  largely  excluded,  a  circumstance  which  explains 
the  multiplication  of  bacteria  and  the  formation  of  ptomaines,  in  carcases 
buried  some  depth  beneath  the  soil.  While  bacteria  in  all  probability 
cannot  live  indefinitely  without  oxygen,  yet  their  fermentative  activity 
can  be  increased  by  reducing  the  oxygen  supply,  for  the  enzymes  or 
chemical  ferments  which  they  form  are  capable  of  acting  under  anaerobic 
conditions.  Since  ptomaines  contain  nitrogen,  they  are  occasionally  spoken 
of  as  bacterial  proteids.  Brieger  and  Frankel  called  them  "  toxalbumins," 
and  ISTeumeister  "  toxic  proteins  "  ;  but  as  they  are  not  all  poisonous,  and  are 
not  all  albumins,  but  albumoses,  globulins,  nucleo-albumins,  and  peptones,  it 
is  simpler  to  retain  the  term  ptomaine,  so  as  to  include  all.  Sidney  Martin, 
Brieger,  and  Cohn  have  lately  succeeded  in  removing  all  extraneous  proteid 
material  from  these  toxines,  with  the  result  that  the  product  obtained  is 
found  to  be  neither  an  albumin  nor  a  proteid.  In  the  processes  of 
fermentation  there  are  concerned  (a)  bacteria,  (5)  the  products  of  bacterial 
secretion  and  excretion,  and  (c)  the  secondary  changes  induced  by  these 
products. 

The  widely  prevalent  use  of  cheap  tinned  foods,  while  admittedly  an 
enormous  boon,  is  yet  not  without  danger.  It  is  estimated  that  581,000  lb. 
of  canned  foods  are  consumed  daily  in  this  country.  According  to  the 
American  Bureau  of  Statistics,  the  export  of  canned  beef  alone  was 
63,698,180  lb.  between  June  1895  and  June  1896.  Brown  of  Bacup  has 
collected  and  grouped  the  reports  of  cases  of  poisoning  from  canned 
foods  that  have  appeared  in  the  home  medical  journals  from  1879  to 
1897.  Twelve  deaths  are  reported.  Canned  meats  and  fish  are  respon- 
sible for  these,  since  no  fatal  poisoning  is  known  to  have  occurred  from 
the  use  of  canned  fruits.  In  the  case  of  tinned  meats,  e.g.  mutton, 
beef,  tongue,  and  rabbit,  a  ptomaine  of  bacterial  origin  probably  underlies 
the  poisoning,  and  this  may  have  been  produced  in  the  meat  (1)  before 
it  was  canned,  (2)  after  canning,  or  (3)  after  the  tin  is  opened.  In  the 
preparation  of  the  meat  and  during  the  steaming  process,  the  toxic 
products  of  ptomaines  if  present  may  be  rendered  inert,  but  the  nutritive 
value  of  the  meat  is  lessened.  Where  ptomaines  have  formed,  after 
canning,  the  gases  produced  by  putrefaction  cause  a  convex  bulging  of 
the  ends  of  the  can,  to  which  the  term  "  blown  "  is  applied  in  the  trade. 
When  such  a  can  is  opened,  the  odour  of  putrefaction  is  so  great  that  there 
can  be  no  doubt  as  to  the  contents  having  become  decomposed.  Once  a 
can  of  sound  meat  has  been  opened,  it  may  be  so  acted  upon  by  conditions 
of  the  atmosphere,  that  bacteria,  finding  a  suitable  nidus  therein,  rapidly 
multiply  and  form  toxines,  which  are  dangerous.  Of  fish,  particularly 
salmon,  this  is  especially  true.  Tinned  salmon  which  exhibits  a  pale 
yellow  colour,  which  is  soft  and  friable,  and  therefore  quite  unlike  the 
firm,  red,  and  flaky  muscle  of  the  healthy  fish,  is  risky.  In  the  case  of 
canned  fruits  the  poisons  are  metallic,  and  arise  from  natural  acids  dis- 
solving out  of  the  solder  tin,  zinc,  or  lead.  The  longer  canned  fruit  is 
allowed  to  remain  in  contact  with  an  impure  solder,  the  greater  is  the 
danger.  All  tinned  meats  should  be  eaten  early,  and  should  be  kept  in  a 
cool  place ;  when  opened  the  contents  should  be  transferred  to  an  earthen- 


MEAT  OR  PTOMAINE  POISONING.  609 

ware  vessel,  and  consumed  within  two  or  three  days,  according  to  the 
weather.     "  Blown  "  cans  should  be  rejected. 

Pathology, — Space  forbids  me  enumerating  all  the  bacteria  that  may 
be  found  in  poisonous  meat,  but  the  following  are  known  to  have  occurred  : 
the  B.  proteus,  B.  prodigiosus,  B.  subiilis,  B.  coli  communis,  B.  tcrmo,  and  the 
Staphylococcus  pyogenes  aureus.  As  regards  the  kind  of  meat  that  has  caused 
poisoning,  Ballard  has  shown  that  of  thirteen  instances  of  meat  poisoning, 
reported  in  England  between  1880  and  1890,  pig  flesh  was  blameable  in  ten 
instances,  veal  in  one,  and  beef  also  in  one.  As  an  illustration  of  the  extent 
of  this  form  of  poisoning,  the  editor  of  the  British  Medical  Journal  states 
that  during  three  months  he  received  reports  of  cases  of  meat  poisoning, 
implicating  upwards  of  sixty  people.  Ballard  believes  that  it  is  on  account 
of  pork  yielding  a  larger  proportion  of  gelatin,  and  affording  therefore  a  more 
suitable  medium  for  the  cultivation  of  micro-organisms,  that  it  is  more 
dangerous,— an  opinion  which  applies  equally  to  veal.  It  is  impossible 
to  say  what  the  mortality  from  meat  poisoning  definitely  is.  There  must 
be  many  cases  of  ptomaine  poisoning  that  are  never  diagnosed.  Of  people 
in  regard  to  whose  illness  there  has  been  no  doubt,  the  death-rate  has 
varied  from  1*6  to  4*3  per  cent.,  whilst  in  the  severer  forms  of  poisoning 
the  illness  has  carried  off  30  per  cent.  During  1893,  in  England  and 
Wales,  nine  males  and  nine  females  died  from  ptomaine  poisoning ;  and 
in  1894,  seven  males  and  ten  females;  while  during  1895-96  the  total 
deaths  were  nine  and  fourteen  respectively.  This  cannot  include  all  the 
cases,  for  there  must  be  many  obscure  forms  of  septicaemia,  pneumonia,  and 
infective  endocarditis,  whose  intestinal  origin  from  decaying  meat  had 
never  suggested  itself.  This  was  the  case  in  the  epidemic  of  pneumonia 
which  so  severely  scourged  Middlesborough  a  few  years  ago.  It  was  not 
until  the  disease  had  existed  some  time,  and  its  rate  of  mortality  ran  high, 
that  Ballard  traced  it  to  the  use  of  "  American  bacon." 

As  opposed  to  ptomaines,  or  the  basic  products  of  putrefaction,  being 
the  materies  morbi,  bacteriologists  mention  other  basic  substances,  which, 
although  the  products  of  fermentative  changes,  are  neither  due  to 
bacterial  activity  nor  to  retrograde  metamorphosis.  To  such  the  term 
leucomaines  is  applied,  a  name  given  by  Gautier  from  Xsuxw/^a,  meaning 
white  of  egg,  to  certain  alkaloids  which  are  formed  in  animal  tissues 
during  normal  life.  They  are  supposed  to  be  continuously  formed 
within  the  body,  side  by  side  with  urea  and  carbonic  acid,  and  at  the 
expense  of  the  nitrogenous  elements.  As  they  are  found  in  the  urine, 
Bouchard,  has  sought  for  an  explanation  of  their  presence  therein  by  sup- 
posing that  their  primary  origin  is  the  intestinal  canal,  from  which  they 
have  been  absorbed.  It  would  appear,  however,  that  the  origin  of  leuco- 
maines is  more  probably  the  metabolism  of  the  nucleated  cells  of  the  body, 
and  that  they  come  under  two  distinct  heads — («)  the  uric  acid,  and  (b)  the 
creatinin  group.  Of  these,  adenin,  which  is  present  in  the  liver  and  urine 
of  leucocythsemic  patients,  guanin,  xanthin,  and  hypoxanthin  may  be 
mentioned.  As  the  nucleus  of  a  cell  is  the  seat  of  considerable  activity,  it 
is  nuclein  that  is  regarded  as  the  parent  substance  of  adenin  and  guanin. 
Many  of  these  alkaloids  are  extremely  poisonous,  so  that  health  is  only 
secured  by  the  integrity  and  functional  activity  of  the  eliminating  organs. 

Extraction  of  ptomaines. — There  are  several  methods  of  extracting 

these  alkaloids,  but  all  of  them  are  surrounded  by  difficulties,  owing  to 

the    fact  that  these    basic    substances    rapidly  undergo    decomposition, 

and   thus    evade   detection;    they   may   be    destroyed    by   the    chemical 

vol.  1. — 39 


610       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

reagents  employed ;  other  complex  compounds  are  frequently  associated 
with,  and  not  easily  separated  from  them ;  and,  finally,  the  reagents 
themselves,  namely,  alcohol,  ether,  etc.,  are  not  always  pure.  The  Stas-Otto, 
Dragendorffs,  Brieger's,  Gautier,  and  Etard's  methods  are  those  chiefly 
used,  but  it  is  admitted  that  no  perfect  method  has  as  yet  been  devised.  As 
the  methods  are  long  and  tedious,  those  who  wish  to  follow  out  this 
part  of  the  inquiry  should  consult  such  recent  works  as  those  by  Yaughan 
and  Novy,  Earquharson  and  G-autier. 

Symptoms. — When  symptoms  of  poisoning  have  arisen  after  the 
ingestion  of  food,  one  of  two  things  must  have  happened — (1)  Either 
the  food  contained  microbes  which  were  present  in  the  flesh  of  the 
animal  at  the  time  it  was  slaughtered,  and  were  not  destroyed  by 
cooking ;  or  (2)  micro-organisms,  subsequently  to  the  death  of  the  animal, 
found  their  way  into  the  meat,  and,  as  the  result  of  their  activity  in 
either  instance,  toxic  products  were  formed.  Infection  of  the  human 
body  may  thus  occur  from  the  entrance  of  disease  germs  or  putrefactive 
bacteria,  and,  whilst  these  are  the  cause  of  the  illness,  the  lesions,  on 
the  other  hand,  are  generally  less  due  to  the  presence  of  micro-organisms 
than  to  the  action  of  their  metabolic  products.  There  is  usually  first  an 
infection,  and  subsequently  an  intoxication,  during  which  poison  is  being 
developed  within  the  system  as  the  result  of  bacterial  activity ;  this  con- 
fers upon  the  disease  its  specific  and  characteristic  signs.  Poisons  which 
have  been  generated  within  the  body  of  another  animal  may  enter  the 
human  body  through  the  alimentary  canal  by  means  of  food.  The  differ- 
ence between  infection  and  intoxication  is,  that  with  infection  there  is  a 
period  of  incubation,  during  which  germs  multiply  before  causing  symptoms, 
while  in  intoxication  symptoms  develop  almost  immediately.  The  circum- 
stance of  a  person  dying  shortly  after  eating  a  particular  food,  in  which 
alkaloids  are  found  capable  of  causing  death  when  administered  to  animals, 
is  an  illustration  of  intoxication ;  but  it  would  be  infection  if  a  bacillus  was 
found,  and  if  the  meat  when  given  to  animals  caused  death  after  a  definite 
time,  corresponding  to  a  period  of  incubation  of  from  twelve  to  twenty-four 
hours.  Opinion  is  still  divided  as  to  how  far  meat  poisoning  is  to  be  regarded 
as  an  illness  of  an  infectious  nature  like  scarlet  fever  or  tuberculosis,  or 
whether  it  is  due  to  cadaveric  alkaloids,  whose  suspected  existence  in 
meat  has  not  always  been  confirmed  when  submitted  to  chemical  analysis. 
There  are  many  pathologists  who  are  sceptical  upon  these  points,  and  who 
cannot  accept  the  general  application  of  the  ptomaine  theory.  Among 
them  is  van  Ermengen,  who,  basing  his  opinion  upon  a  recent  epidemic  of 
poisoning  by  meat  at  Moorseele,  has  arrived  at  the  conclusion  that  this 
form  of  poisoning  arises  from  two  sources — (1)  Eating  the  flesh  of  animals 
killed  during  illness,  and  (2)  the  use  of  made-up  dishes,  hashed  meat,  pies, 
sausages,  etc.,  in  the  manufacture  of  which,  as  for  example,  during  the 
process  of  mincing  and  mixing,  portions  of  internal  viscera  have  slipped  in, 
such  as  spleen,  liver,  lungs,  kidneys,  or  intestine.  It  is  in  these  organs  of 
an  animal  which  has  died  of  an  acute  infectious  malady,  that  micro- 
organisms and  their  toxines  would  most  abundantly  prevail.  It  is  now 
several  years  since  our  attention  was  drawn  to  poisoning  by  sausages,  an 
accident  to  which  the  term  botulisme  is  applied.  Meat  undergoing  putre- 
faction is  justly  condemned,  but  at  first  sight  it  seems  scarcely  credible 
that  the  flesh  of  very  young  healthy  animals  should  favour  auto-intoxica- 
tion. It  is  Charrin's  opinion  that  auto-infection  of  man  may  arise  from 
the  micro-organisms  which  normally  inhabit   his   intestine  having  their 


MEAT  OR  PTOMAINE  POISONING.  61 1 

virulence  increased  by  toxic  materials,  introduced  by  food  that  is  beginning 
to  decompose.  According  to  him,  veal  constitutes  in  the  digestive  canal  a 
gelatinised  pulp,  which  is  highly  favourable  to  the  multiplication  of  the 
intestinal  bacteria. 

After  the  ingestion  of  meat  containing  micro-organisms,  present  in  the 
flesh  of  an  animal  when  it  died,  several  hours  or  a  day  or  two  may  elapse 
before  symptoms  appear.  There  is  a  period  of  incubation  similar  to  that 
in  infectious  diseases.  When  meat  is  eaten  that  has  been  invaded  by 
microbes  subsequent  to  the  slaughter  of  the  animal,  there  is  generally  a 
period  of  incubation.  In  such  a  case,  there  is  probably  associated  with 
the  bacteria  the  toxines  they  have  formed;  and  if  so,  symptoms  of  toxaemia 
will  rapidly  show  themselves,  followed  sooner  or  later  by  those  of  the 
infective  disease.  Where  meat  contains  only  alkaloids  or  ptomaines,  the 
symptoms  are  those  of  chemical  poisoning,  and  these  may  appear  shortly 
after  eating  the  food,  or  be  delayed  for  several  hours. 

Infectious  disease  may  arise  in  various  ways.  Certain  microbes  are 
known  to  be  poisonous  to  the  human  body.  They  produce  chemical 
ferments  therein,  or  form  chemical  poisons  by  splitting  up  pre-existing 
compounds.  The  entrance  into  the  system  of  micro-organisms  will  not 
only  cause  disease,  but  confer  upon  the  disease  an  infectious  character. 
Microbes  multiply  and  elaborate  chemical  compounds  within  the  system, 
which  are  capable  of  inducing  particular  effects.  It  is  sometimes  difficult 
to  distinguish  between  symptoms  due  to  infection  and  those  consequent 
upon  chemical  poisoning.  The  symptoms  of  the  latter  occasionally 
resemble  those  observed  in  acute  gastro-enteritis,  namely,  purging, 
vomiting,  cramps  in  the  legs,  an  elevated  or  subnormal  temperature, 
followed  by  death  within  a  few  days.  Given  a  case  where  poisoned 
meat  has  been  eaten,  it  is  impossible  to  say  what  symptoms,  if  any, 
will  follow.  Much  depends  upon  the  particular  bacterium,  the  organic 
medium  it  is  developing  in,  the  stage  of  putrefaction  reached,  and  the 
resistance  or  idiosyncrasy  of  the  individual.  The  symptoms  would  pro- 
bably be  in  succession — (1)  gastro-intestinal,  (2)  nervous,  (3)  cardiac,  (4) 
skin  eruptions,  (5)  inflammation  of  serous  membranes,  and  (6)  albuminuria  ; 
but  the  period  at  which  these  show  themselves  varies,  owing  to  the  fact 
that,  while  the  illness  might  begin  as  an  infection,  it  is  usually  followed  by 
an  intoxication,  consequent  upon  absorption  of  the  products  elaborated  by 
the  micro-organisms.  Bacteria  are  thus  able  to  act  in  a  double  way 
through  their  own  secretions.  Gautier  and  Etard  have  shown  that  during 
putrefaction  the  acid  reaction  which  is  present  in  the  experimental  tube 
during  the  first  few  days,  and  which  is  due  to  the  presence  of  lactic  acid, 
becomes  replaced  by  a  reaction  that  is  alkaline.  It  is  at  this  stage 
that  there  appears  a  series  of  basic  alkaloids,  like  choline  and  neurine 
(Brieger),  the  latter  being  extremely  toxic,  and  differing  from  choline 
in  containing  one  molecule  less  of  water;  subsequently,  that  there 
arise  neuridine,  parvoline,  collidine  or  hydrocollidine  (Pouchet),  bodies 
which  possess  strong  convulsive  properties,  and  which  determine  effects 
similar  to  those  of  muscarine,  namely,  salivation,  dyspnoea,  respiratory 
weakness,  and  cardiac  failure,  and  which,  since  they  are  capable  of  havino- 
their  effects  neutralised  by  atropine,  are  occasionally  called  ptomatropine. 

One  of  the  earliest  illustrations  in  this  country  of  the  bad  effects 
arising  from  eating  ham  containing  toxines  from  putrefaction  was  the 
Welbeck  poisoning  case.  In  June  1880  there  was  a  sale  of  timber  and 
machinery  on  the  estate  of  the  Duke  of  Portland,  at  Welbeck.     The  sale 


612        DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

lasted  four  days,  and  was  attended  by  a  large  number  of  people. 
Luncheons  were  served  in  a  neighbouring  hotel,  and  consisted  of  cold 
boiled  ham,  cold  boiled  and  roasted  beef,  cold  beef-steak  pie,  bread,  cheese, 
pickles,  and  chutney  sauce.  The  drinks  were  bottled,  and  draught  beer, 
spirits,  ginger-beer,  lemonade,  and  water.  Seventy-four  people  were 
poisoned,  of  whom  four  died.  Ballard,  in  investigating  the  outbreak, 
reported  that  diarrhoea  was  one  of  the  most  common  symptoms,  that  a 
period  of  incubation  preceded  the  illness,  varying  from  twelve  to  forty- 
eight  hours ;  that  whereas  in  some  the  symptoms  developed  suddenly,  in 
others  there  was  an  incubation  period,  during  which  there  were  languor, 
loss  of  appetite,  nausea,  fugitive  abdominal  pains,  followed  by  a  sense  of 
chilliness  or  distinct  rigors,  giddiness,  faintness,  staggering  gait,  headache, 
cold  clammy  sweats,  difficulty  of  swallowing,  vomiting,  and  diarrhoea. 
Extreme  debility  was  one  of  the  most  characteristic  symptoms.  The  tem- 
perature ranged  from  99°  to  104°  F.,  and  the  pulse  from  88  to  128.  In 
the  fatal  cases  death  was  preceded  by  collapse  and  by  signs  not  unlike 
those  of  cholera,  namely,  cyanosis  and  coldness  of  the  extremities.  Ballard 
traced  the  illness  to  the  hams  that  had  been  eaten.  Klein  found  in  them 
a  bacillus,  cultures  of  which,  when  inoculated  into  animals,  were  followed 
by  pneumonia.  The  Welbeck  case  demonstrates  what  so  frequently 
happens,  namely,  that  toxines  give  rise  to  different  symptoms  in  different 
people,  partly  owing  to  the  fact  that  there  may  be  more  than  one  toxine 
present  in  the  meat,  and  that  they  are  not  evenly  distributed  through- 
out the  carcase  of  the  animal.  It  is  thus  that  we  seek  to  explain,  not 
only  the  variability  of  the  symptoms,  but  the  negative  results  that  follow 
the  subjection  of  meat  to  a  chemical  or  bacteriological  examination, 
for  the  most  poisonous  parts  of  the  food  may  already  have  been  eaten. 
Death  may  follow  the  ingestion  of  decomposing  meat,  and  yet  careful 
examination,  conducted  by  skilful  analysts,  may  fail  to  detect  the  alkaloids 
that  caused  the  poisoning,  owing  to  the  ptomaines  in  the  process  of 
analysis  becoming  split  up  into  non-poisonous  bodies,  and  also,  as  Dixon 
Mann  believes,  owing  to  such  poisoning  being  the  joint  result  of  the 
bacteria  and  their  formed  ferments.  Many  so-called  toxines  are  not  basic 
products  at  all,  but  toxalbumoses,  and  of  these  we  know  little  beyond  the 
fact  that  they  are  unstable  bodies,  not  crystallisable,  whose  presence  is 
only  indicated  by  the  characteristic  effects  which  they  produce  upon 
animals.  Besides,  there  is  an  individual  as  well  as  a  racial  idiosyncrasy  to 
such  poison.  A  disagreeable  odour  emanating  from  meat  is  no  doubt  more 
or  less  significant.  There  is  a  stage  in  the  putrefaction  of  meat  which  is 
dangerous,  yet  if  decomposition  is  allowed  to  proceed  further,  the  danger 
disappears.  On  the  other  hand,  the  flesh  of  an  animal  slaughtered  on  account 
of  illness  may  be  eaten  with  impunity  immediately  after  death,  but  if  kept 
for  a  few  days  it  may  become  toxic.  The  flesh  of  animals  that  are  suffer- 
ing from  such  septic  diseases  as  hsemorrhagic  enteritis,  multiple  arthritis, 
post-par  turn  metritis,  etc.,  is,  if  the  animals  are  killed  in  extremis,  always 
more  dangerous  than  if  destroyed  in  the  earlier  stages  of  the  illness.  It  is 
not  to  be  inferred  from  this,  however,  that  absolute  safety  is  obtained  by 
early  slaughtering.  Basenau  mentions  an  experiment  carried  out  in 
the  slaughter-house  at  Eotterdam,  where  an  ox  was  inoculated  in  the 
jugular  vein  with  a  culture  containing  bacilli  got  from  a  meat-poisoning 
case.  The  animal  was  killed  twenty  minutes  after  the  inoculation,  and 
while  at  first  only  a  few  bacilli  were  found  in  its  blood,  liver,  and  spleen, 
these  micro-organisms  rapidly  increased  in  number  within  a  few  hours. 


MEAT  OR  PTOMAINE  POISONING.  613 

As  only  very  few  bacilli  were  found  in  the  muscular  tissue  of  the 
animal,  it  was  presumed  that  if  eaten  early  little  risk  attended  the  use 
of  it.  Fifty-three  persons  resolved  to  try  it ;  of  these,  fifteen  became 
ill  with  headache  and  diarrhoea  after  a  lapse  of  twelve  to  eighteen  hours, 
but  all  recovered.  Those  who  do  not  accept  the  ptomaine  theory  of  meat 
poisoning  support  their  arguments  by  appealing  to  facts  that  are  well 
known  to  most  of  us.  In  our  large  towns,  late  on  a  Saturday  evening,  it  is 
no  uncommon  sight  to  see  crowds  of  poor  people  around  a  butcher's  or  a 
poulterer's  stall,  bidding  for  meat,  fish,  and  game  that  are  already  in  an  ad- 
vanced stage  of  decomposition.  These  people  do  not  seem  to  suffer  any  in- 
convenience from  eating  such,  but  rather  thrive  upon  it.  Oriental  people 
also  appear  to  be  indifferent  to  the  wholesomeness  of  their  food.  According 
to  Novarre,  rotten  fish  constitutes  the  food  by  preference  of  millions  of 
Indians,  Indo-Chinese,  Malayans,  Polynesians,  and  Negroes,  who  nourish 
themselves  upon  this  mess,  even  preferring  it  when  decomposition  is  most 
advanced.  The  taste  of  many  British  sportsmen  lies  in  the  same  direction ; 
they  like  their  game  "high."  It  is  fortunate  that  the  gastric  juice,  in 
addition  to  being  a  digestive,  is  also  antiseptic,  otherwise  serious  con- 
sequences would  oftener  follow.  With  these  facts  before  us,  the  question 
naturally  arises,  whether  putrefaction,  pure  and  simple,  can  be  held 
responsible  for  the  illness  that  follows  the  eating  of  decayed  meats.  In  an 
epidemic  at  Frankenhausen,  carefully  investigated  by  Gartner,  the  meat 
did  not  present  the  slightest  appearance  of  putrid  change.  Again,  micro- 
organisms and  ptomaines  may  be  present  in  meat,  and  as  to  their  virulence 
there  may  be  no  doubt,  but  it  is  scarcely  fair  to  argue,  when  these 
substances  have  been  injected  into  the  subcutaneous  tissues,  the  veins  or 
peritoneal  sac  of  animals,  and  symptoms  have  followed,  that  poisoning  would 
have  been  induced  had  the  same  substances  been  administered  by  the 
alimentary  canal.  When  introduced  into  the  body  by  this  channel,  many 
of  these  substances  lose  their  poisonous  properties,  and  in  order  to  produce 
their  effects  it  is  necessary  to  give  them  in  larger  quantities.  This  argu- 
ment covers  only  part  of  the  ground,  however,  for  some  animals  are  re- 
fractory to  certain  poisonous  foods  when  taken  by  the  stomach,  whilst  others 
suffer  equally  with  men,  whether  the  poison  enters  by  the  alimentary  canal 
or  by  intravenous  injection.  In  the  human  subject  there  is  a  similar  idiosyn- 
crasy, so  that  while  some  people  can  eat  decomposing  meat,  and  hardly 
suffer,  others  are  made  seriously  ill  or  die.  It  is  difficult  to  explain  the 
variation  of  symptoms  in  different  people.  Wiedner  relates  that  of 
ninety  people  who  were  ill  through  eating  roast  goose,  some  suffered  from 
pain  in  the  abdomen  and  vomiting;  others  had  diarrhoea;  in  some  the 
symptoms  were  those  of  cholera  nostras ;  in  others  there  were  cramp-like 
pains  in  the  muscles  of  the  extremities  and  neck.  Toxine  poisoning  may 
follow  the  ingestion  of  meat,  which  exhibited  no  trace  of  putrefaction  at 
the  time  it  was  eaten.  It  may  have  contained  bacilli,  capable  of  producing 
ptomaines.  On  the  other  hand,  toxic  meat  may  lose  its  poisonous  pro- 
perties as  putrefaction  advances,  not  so  much  from  bacteria  dying  off,  as  in 
consequence  of  an  alteration  in  the  products  of  decomposition  they  lose 
their  poisonous  properties.  Klein  found  a  bacillus  in  some  fresh  meat-pie 
which  had  made  several  people  ill,  and  which  caused  death  when  given  to 
mice.  After  keeping  the  pie  for  several  days,  by  which  time  an  intensely 
putrefactive  odour  had  developed,  it  was  found  to  have  lost  its  poisonous 
properties,  for  mice  now  fed  upon  it  no  longer  suffered.  Cooking  usually 
destroys  both  the  micro-organisms  and  their  poisonous  alkaloids,  but  just 


6 14       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

as  the  spores  of  certain  bacteria  are  capable  of  resisting  great  heat,  so  some 
toxines  are  similarly  endowed  with  the  capability  of  resisting  temperatures 
that  are  fatal  to  micro-organisms.  Once  meat  has  become  impregnated 
with  ptomaines,  there  is  no  certainty  that  cooking  will  ever  render  the 
flesh  harmless.  There  may  be  no  disagreeable  odour  arising  from  it. 
Flesh  meat  that  yields  either  a  sweet  or  a  sour  odour,  without  anything  of  the 
nature  of  putrefaction  about  it,  is,  however,  often  more  dangerous  than  that 
which  is  decomposing.  This  is  probably  owing  to  the  fact  that  the  more 
poisonous  toxalbumoses  are  formed  in  the  earliest  stages  of  putrefaction  by 
bacteria,  at  a  time  prior  to  that  in  which  a  more  general  disintegration  of 
tissue  proteid  takes  place,  whereby,  as  decomposition  advances,  ptomaines 
are  formed,  some  of  which  only  are  poisonous.  Meat  which  was  perfectly 
safe  when  eaten  warm  may  change  after  cooling  and  keeping.  It  may  then 
become  the  arena  of  bacterial  activity,  and  the  seat  of  the  formation  of 
alkaloids.  A  few  years  ago  I  was  called  to  the  Newcastle  Industrial 
Schools,  to  deal  with  an  outbreak  of  diarrhoea,  which  had  suddenly 
developed.  Nearly  the  whole  school  had  been  stricken.  Two  days 
previously  the  inmates  had  enjoyed  their  Sunday's  dinner  of  roast 
beef.  The  meat  left  over  was  warmed  up  and  eaten  on  the  following 
day.  On  the  Tuesday  morning  there  was  ah  epidemic  of  diarrhoea,  up- 
wards of  a  hundred  lads  being  ill.  Those  children  who  had  not  partaken 
of  the  warmed-up  meat,  although  placed  under  the  same  dietetic  conditions, 
except  as  regards  this  one  particular  meal,  alone  escaped.  In  keeping  cold 
cooked  meat  for  a  few  days,  risk  is  sometimes  run,  for  during  this  period  it 
may  become  contaminated,  owing  to  the  fact  that  some  bacteria  multiply 
at  a  very  low  temperature,  32°  F.  The  circumstance  of  the  meat  having 
been  kept  even  in  an  ice  safe  is  no  absolute  guarantee  against  the 
possibility  of  bacterial  invasion.  The  air  of  an  ice  chamber  should  be  free 
as  far  as  possible  from  moisture,  and  the  meat  kept  dry  as  well  as  cold,  for 
only  thus  can  it  remain  fresh.  The  drawback  to  the  use  of  the  cooked 
pies  that  are  sold  in  shops,  of  sausages,  pickled  meats,  etc.,  is  that  we  have  no 
proof  of  the  soundness  of  the  meat  employed  in  their  manufacture. 
Unsound  meat  is  sometimes  pickled  in  the  hope  of  getting  rid  of  an 
unpleasant  odour,  but  this  does  not  remove  the  poisonous  alkaloids.  The 
muscle  of  meat  is  always  less  dangerous  than  any  of  the  internal  organs. 

We  know  that  risk  is  incurred  by  eating  putrid  fish,  but  poisoning  may 
follow  the  ingestion  of  fresh  fish,  lobster,  crab,  and  oysters,  for  these  may 
have  acquired  poisonous  properties  from  the  medium  in  which  they  were 
caught,  as  for  example  water  adulterated  by  the  sewage  of  towns  or 
polluted  by  factory  refuse.  Oysters  reared  near  the  mouth  of  rivers 
contaminated  by  the  sewage  of  towns  have  caused  illness  resembling 
typhoid  fever.  The  fatal  illnesses  that  followed  the  ingestion  of  oysters  at 
the  Stirling  County  Ball  a  winter  or  two  ago  were  a  convincing  demonstra- 
tion of  the  virulent  effects  of  poisons  that  may  be  locked  up  within  this  edible 
bivalve.  Similar  effects  have  followed  the  eating  of  tinned  salmon,  sardines, 
etc.  Admitting  that  the  fish  were  healthy  when  placed  in  the  tin,  once 
this  is  opened  and  kept  exposed  to  the  air  certain  changes  may  occur  which 
render  the  contents  extremely  poisonous.  Symptoms  rapidly  develop  after 
eating  such  fish,  except  in  the  case  of  oysters,  when  there  is  usually  greater 
delay ;  and  while  the  symptoms  vary  in  accordance  with  the  cause  and  the 
idiosyncrasy  of  the  patient,  fever  is  not,  as  a  rule,  present,  nor  is  there 
diarrhoea,  but  rather  constipation,  tenesmus,  and  bloody  evacuations. 
Usually  there  are  vomiting,  cardiac  and  respiratory  distress,  nervous  symp- 


MEAT  OP  PTOMAINE  POISONING.  615 

toms,  perspiration,  and  contracted  pupils,  along  with  erythema  or  urticaria, 
particularly  in  poisoning  by  crab.  In  oyster  poisoning,  symptoms  are  more 
slowly  developed,  and  these  are  indigestion,  with  a  feeling  of  faintness, 
followed  by  nervous  symptoms,  and  frequently  accompanied  by  erythematous 
patches  in  the  skin,  or  by  intense  itching.  From  toxic  mussels,  Brieger, 
Salkowski,  and  Seeger  obtained  an  alkaloid,  known  as  mytiloxine.  This 
substance  acts  like  curari,  but  has  in  addition  the  power  of  contracting  the 
pupil.  Brieger  obtained  from  decaying  fish,  ptomato-muscarine ;  Boklisch 
from  putrefying  perch  got  guanadine;  whilst  Gautier  and  Etard  have 
isolated  a  series  of  toxic  bases,  e.g.  hydrocollidine,  which  produces  con- 
vulsions and  causes  death,  with  the  heart  arrested  in  diastole ;  parvoline 
and  muscarine ;  and  from  cod-liver  oil  trimethylamine.  Mydaleine,  obtained 
from  the  human  cadaver,  causes,  when  injected  into  animals,  the  symptoms 
of  alkaloidal  poisoning,  with,  in  addition,  a  rise  of  temperature,  dilatation 
of  the  pupils,  and  a  tendency  to  paralysis  and  convulsions. 

Milk,  cheese,  and  butter  may  cause  poisoning.  Milk  may  contain  de- 
leterious material  owing  to  the  animal  which  supplies  it  having  previously 
eaten  some  metallic  poison,  or  injurious  plants.  It  may  also  contain  micro- 
organisms, such  as  the  tubercle  or  typhoid  fever  bacillus.  Cheese  may  under- 
go putrefaction  and  develop  such  toxic  alkaloids  as  tyrotoxine  (Vaughan), 
trimethylamine,  neuridine,  and  toxalbumins.  The  symptoms  which  these 
cause  differ  little  from  those  already  described,  except  that  in  addition 
there  is  diplopia,  as  mentioned  by  Teissier.  Poisoning  by  butter  is  not 
unknown.  Sir  Charles  Cameron  states  that  in  a  family  which  had  break- 
fasted upon  bread,  butter,  and  tea,  all  the  members  with  one  exception 
suffered  from  choleraic  diarrhoea.  The  individual  who  escaped  had  refused 
to  eat  the  butter,  on  account  of  its  intense  rancidity.  So  severe  were  the 
symptoms,  that  one  of  the  children  died.  In  another  instance  a  family 
developed  choleraic  diarrhoea.  All  the  members  had  eaten  very  rancid 
butter,  and  all  suffered.  In  the  butter,  on  analysis,  there  were  found 
ptomaines  in  large  quantity. 

Scurvy,  hitherto  believed  to  be  caused  by  the  absence  of  fresh  vege- 
tables in  the  dietary,  is  now  considered  to  be  dependent  upon  the 
consumption  of  tainted  and  salted  meat. 

Diagnosis. — The  illness  is  one  of  sudden  development.  Usually 
several  healthy  people  are  simultaneously  seized,  and  there  is  a  history 
of  a  particular  kind  of  food  having  been  eaten.  There  may,  however,  be 
a  period  of  incubation,  either  of  hours  or  of  a  few  days ;  only  a  few 
hours  if  it  is  alkaloidal  poisoning,  a  few  days  if  it  is  infection.  The 
latter  will  depend  upon  the  kind  and  number  of  the  micro-organisms. 
In  the  Middlesborough  epidemic  of  pneumonia  the  period  of  incubation 
varied  from  eighteen  to  thirty-six  hours.  The  symptoms  originating  in 
the  alimentary  tract  are  followed  by  those  of  the  nervous  system ;  there 
is  extreme  exhaustion,  free  perspiration,  and  a  tendency  to  respiratory 
and  cardiac  failure.  Since  bone  marrow  is  acknowledged  to  form  a 
good  resting-place  for  micro-organisms,  these  may  find  their  way  thereto 
from  the  intestinal  tract  and  set  up  an  osteomyelitis,  which  can  only  thus 
be  explained. 

Prognosis. — The  prognosis  is  grave  in  most  cases,  but  it  is  relative 
to  the  character  of  the  symptoms.  Eepeated  vomiting  and  diarrhoea, 
nervous  phenomena,  extreme  muscular  debility,  and  albuminuria,  indicate 
rather  a  severe  type  of  meat  poisoning. 

Treatment. — Abolition  of   private  slaughter-houses  and   a   careful 


616       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES 

examination  of  the  carcases  of  animals  by  a  skilled  public  officer;  pro- 
hibition of  the  use  of  the  flesh  of  animals  killed  on  account  of  puerperal 
septicaemia  and  other  blood  diseases;  also  those  that  have  died  from 
acute  enteritis  and  pneumo-enteritis  ;  such  strict  supervision  of  the  lower 
class  of  butchers,  that,  under  heavy  penalties,  it  will  be  impossible  for 
them  to  sell  or  convert  suspected  meat  into  hams,  sausages,  and  pies. 
Absolute  security,  however,  cannot  be  obtained.  We  must  rely  to  a  very 
large  extent  upon  the  honesty  and  the  care  exercised  in  the  buying  and 
selling  of  meat  by  our  butchers,  and  of  the  integrity  of  sausage-makers,  so 
that  they  will  not  include  in  the  manufactured  articles  portions  of  the 
internal  organs  of  animals  slaughtered  for  disease.  Scrupulous  cleanliness 
all  round  is  a  necessity,  not  only  of  the  hands  of  those  who  cut  up  the 
meat,  but  of  the  rooms  in  which  it  is  kept  and  disposed  of, — rooms  which 
should  be  cool,  well  ventilated,  and  far  removed  from  drains  and  all  chance 
of  contamination  by  sewer  gas.  Tinned  meats  should  be  examined  before 
being  eaten,  and  all  tins  should  be  rejected  if  they  have  been  bruised, 
"  blown,"  or  opened  in  their  transit.  Those,  too,  should  be  rejected,  the 
jelly  of  which,  when  exposed,  is  found  to  have  become  liquefied,  or  from 
which  a  putrefactive  odour  is  escaping.  Milk  that  might  contain  tubercle 
bacilli  should  be  boiled. 

In  meat-poisoning  the  period  which  elapses  between  the  ingestion  of 
the  food  and  the  appearance  of  the  symptoms  is  a  point  of  importance. 
The  early  development  of  symptoms  indicates  intoxication  due  to  one  or 
several  ptomaines,  whereas  if  delayed  for  twelve  or  fifteen  hours  it  sug- 
gests the  probability  of  microbial  infection ;  but  again  I  repeat,  that  this 
distinction  is  not  absolute,  although  quite  sufficient  for  a  fair  inference  to 
be  drawn  between  ptomaine  and  bacterial  poisoning,  and  to  be  a  guide  as 
regards  treatment.  When  gastric  symptoms  appear  early,  an  attempt 
should  be  made  to  empty  the  stomach  by  emetics,  or  the  stomach-pump, 
or  to  clear  out  the  intestinal  tract  by  cathartics,  in  the  hope  of  preventing 
further  absorption.  In  a  case  of  bacterial  infection  without  diarrhoea,  a 
gentle  purgative  like  castor-oil  can  do  no  harm.  A  solution  of  tannin  is 
recommended,  on  the  ground  that  it  precipitates  alkaloids,  but  we  still 
require  proof  of  its  utility.  We  should  try  to  render  the  contents  of  the 
intestine  aseptic,  and  prevent  if  possible  the  multiplication  of  germs 
therein.  Bouchard,  Lauder  Brunton,  and  others  have  shown  what  excel- 
lent results  follow  a  rigid  intestinal  antisepsis.  The  salicylate  of  soda,  by 
promoting  the  flow  of  bile  which  is  itself  antiseptic  and  an  aid  to  intes- 
tinal peristalsis,  is  worthy  of  a  trial  if  the  patient  is  already  not  too  much 
depressed.  Of  the  efficacy  of  naphthol-beta  and  salol,  I  can  speak 
most  approvingly,  as  also  of  sulpho-carbolate  of  socla  in  15  to  30  gr. 
doses  three  or  four  times  a  day.  Next  to  intestinal  antisepsis  comes  anti- 
dotal treatment,  if  the  particular  alkaloid  can  be  determined.  Several  of 
these  alkaloids  behave  like  muscarine,  and  cause,  among  other  symptoms, 
contraction  of  the  pupil.  Atropine  is  the  antidote  to  such  alkaloids ;  it 
may  be  administered  subcutaneously  in  from  -^q  to  -£6  gr.,  and  repeated 
within  half  an  hour  if  necessary.  Some  ptomaines,  on  the  other  hand, 
behave  like  atropine,  and  cause  dryness  of  the  throat,  increased  intestinal 
peristalsis,  and  dilatation  of  the  pupil.  Their  influence  should  be  combated 
by  subcutaneous  injection  of  morphine  or  small  doses  of  pilocarpine.  For  the 
remainder,  symptoms  must  be  treated  as  they  arise — convulsions  may  be 
treated  by  potassium  bromide  ;  faintness  by  ether,  ammonia,  caffeine,  or 
strophanthus  ;  vomiting,  if  excessive,  by  sinapisms  to  the  epigastrium,  or 


POISONING  BY  VEGETABLE  ALKALOIDS,  ETC.  617 

internally  by  ice  and  effervescing  mixtures ;  pyrexia,  by  quinine  or 
salicylate  of  soda  ;  constipation,  by  mild  purgatives ;  whilst  diarrhoea,  if 
not  profuse,  is  best  left  alone.  We  seek  to  favour  elimination  by  the 
kidneys  and  skin,  and,  above  all,  we  maintain  the  strength  of  the  patient 
by  stimulants,  milk,  strong  animal  soups,  and  concentrated  but  easily 
digested  foods. 


POISONING  BY  VEGETABLE  ALKALOIDS  AND  OTHEE 
ACTIVE  PEINCIPLES. 

We  apply  the  term  alkaloids  to  substances  of  a  basic  nature  formed  in 
the  tissues  of  plants  or  animals,  and  which  are  capable,  like  alkalies, 
of  combining  with  acids  to  form  salts.  It  is  to  these  bases  that  plants 
owe  their  physiological  properties.  They  contain  carbon,  hydrogen,  and 
nitrogen,  and  all  of  them  oxygen,  with  the  exception  of  conine,  nicotine, 
and  spartein.  Extremely  complex  in  their  chemical  composition, 
alkaloids  have  been  grouped  with  the  amines  or  amides,  ammonia  sub- 
stances, one  or  two  of  whose  hydrogen  atoms  have  been  replaced  by  a 
radicle.  One  of  the  principal  characteristics  of  the  group  is  instability. 
They  readily  decompose  under  the  influence  of  temperature  and  oxidisino- 
agents,  but  particularly  when  acted  upon  by  micro-organisms.  It  is  thus 
that,  after  death  from  alkaloidal  poisoning,  the  alkaloid  itself  may  disappear 
from  the  body  through  decomposition ;  hence  the  necessity,  in  a  suspected 
case  of  this  form  of  poisoning,  for  examining  the  body  shortly  after  death. 

History. — The  discovery  of  alkaloids  marks  an  important  step  in 
chemistry  and  therapeutics.  Formerly  it  was  believed  that  vegetables 
contained  only  a  few  organic  acids,  but  Derosne,  when  investigating 
certain  medicinal  plants  in  1803,  discovered  a  substance  with  an  alkaline 
reaction,  to  which  he  gave  the  name  of  opium  salt,  and  which  in  1804  was 
recognised  by  Sertiiner  as  morphine.  Since  then,  by  improved  chemical 
methods,  numerous  alkaloids  have  been  added  to  the  list;  these  retain 
as  their  terminals  the  letters  ine,  e.g.  morphine ;  whereas,  for  non-alkaloidal 
active  principles,  the  letters  intern  or  in  are  generally  employed,  as  in 
digitalinum  and  digitalin.  The  simplest  chemical  compound  belongino-  to 
the  group  of  ring-formed  atomic  complexes,  i.e.  substances  which  contain 
carbon  and  hydrogen,  but  in  which  the  ring  is  capable  of  being  closed  by 
an  atom  of  nitrogen,  is  pyridine,  a  product  obtained  from  coal  tar.  All 
alkaloids  obtained  from  plants  that  act  injuriously  upon  the  human  body, 
are  modifications  of  pyridine.  Our  knowledge  of  the  atomic  relationships 
of  pyridine  has  enabled  the  chemist  to  synthetically  form  various  alkaloids. 

Etiology  and  symptoms. — The  part  played  by  alkaloids  in  the 
functional  life  of  plants  is  not  known.  More  than  one  alkaloid  may 
be  found  in  the  same  plant ;  and  while  many  of  these  are  extremely 
virulent  poisons,  others  are  innocuous.  It  is  characteristic  of  them,  as 
opposed  to  mineral  poisons,  that  they  produce  symptoms  almost  imme- 
diately after  entering  the  system — symptoms  which  run  a  rapid  course, 
and  with  increasing  severity.  To  this  rule  there  are  exceptions,  as  witness 
the  tardy  development  of  symptoms  in  morphine  poisoning.  Nearly  all 
alkaloids  exert  their  baneful  influence  upon  the  nervous  system.  In  some 
instances  there  is  also  considerable  derangement  of  the  digestive  tract.  As 
regards  reaction  to  alkaloids,  there  is  not  only  in  the  human  subject  but  in 


618       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

animals  a  varying  susceptibility.  This  idiosyncrasy  in  man  is  shown  by  the 
manner  in  which  some  people  are  influenced,  by  minute  doses  of  morphine 
and  quinine  compared  to  others,  and  in  animals  by  the  susceptibility  of 
the  dog,  for  example,  to  minute  doses  of  atropine,  whilst  upon  rabbits 
the  drug  is  practically  harmless.  Experimental  data  thus  obtained  are 
not  therefore  of  general  application.  The  intensity  of  the  action  of 
alkaloids  is  largely  dependent  upon  the  complexity  of  their  molecular 
structure  and  the  sum  of  their  atomic  weights ;  on  the  other  hand,  the 
rapidity  with  which  their  physiological  effects  are  produced  is  dependent 
upon  their  easy  transition  from  complex  to  simpler  bodies.  The  effects, 
too,  are  largely  determined  by  the  purity  of  the  alkaloid  and  the  develop- 
ment of  the  nervous  system  of  the  victim.  The  nervous  symptoms  are 
proportional  to  the  organisation  of  the  animal,  and  as  in  some  animals 
certain  parts  of  the  nervous  system  are  more  highly  developed  than 
others,  so  are  the  effects  of  alkaloidal  poisoning  correspondingly  exhibited 
by  the  spinal  cord  or  the  cerebrum. 

Space  only  allows  of  our  mentioning  a  few  of  the  principal  vegetable 
alkaloids,  and  their  physiological  effects;  but  before  doing  so  we  may 
briefly  allude  to  the  general  lines  of  treatment  to  be  followed  in  cases  of 
alkaloidal  poisoning.  In  order  to  be  successful,  the  patient  requires  to  be  seen 
early,  and  the  stomach  washed  out  at  once.  Where  this  is  impossible,  we 
may  administer  substances  to  render  the  alkaloid  less  soluble,  and  for  this 
purpose,  tannin,  iodine  dissolved  in  potassium  iodide,  or  the  administration 
of  finely  divided  charcoal,  which,  by  mechanically  uniting  with  the 
poison,  retards  its  absorption,  are  recommended.  Once  the  poison 
has  been  absorbed,  attention  must  be  directed  to  the  more  serious 
symptoms,  depending  upon  implication  of  the  nervous  system,  and 
which  require  to  be  met  by  such  drugs  as  chloral,  chloroform,  ammonia, 
and  caffeine. 

Aconitine  poisoning  is  rare.  The  usual  symptoms  are  numbness 
and  tingling  in  the  lips,  tongue,  and  throat,  burning  pain  in  stomach, 
nausea,  and  vomiting.  So  benumbed  are  the  mouth  and  throat,  that 
swallowing  becomes  almost  impossible.  There  is  cold  perspiration, 
feeble  heart's  action,  extreme  prostration,  and  death  from  syncope,  occa- 
sionally preceded  by  convulsions  and  delirium.  Aconitine  is  one  of  the 
most  active  and  rapid  poisons  with  which  we  are  acquainted.  One  six- 
teenth of  a  grain  (^g)  has  caused  death  in  a  few  minutes.  In  the  body, 
after  death,  there  are  no  pathological  appearances  that  are  either  constant 
or  conclusive. 

In  atropine  poisoning  the  symptoms  usually  begin  within  an  hour  of 
swallowing  the  poison,  and  consist  of  great  dryness  of  mouth  and  throat, 
difficulty  of  swallowing,  imperfect  vision  with  very  dilated  pupils,  delirium, 
difficult  articulation,  feeble,  rapid,  and  intermittent  pulse,  reddening  of  skin, 
coma  and  convulsions.  The  quantity  of  atropine  required  to  cause  death 
depends  upon  the  channel  of  its  administration.  Half  a  grain  given  by  the 
mouth  has  caused  death,  and  ^  of  a  grain  administered  hypodermically. 
Kecovery  from  large  doses  has  taken  place.  The  principal  post-mortem 
appearances  are  dilated  pupils,  hyperemia  of  mucous  membrane  of 
stomach  and  intestines,  congested  lungs,  and  empty  heart.  The  treat- 
ment for  atropine  poisoning,  in  addition  to  that  already  mentioned  on 
general  lines,  is  the  hypodermic  injection  of  morphine  in  £-gr.  doses  from 
time  to  time.  As  the  alkaloid  is  eliminated  by  the  kidneys,  it  is  well  to 
catheterise  the  bladder,  not  only  on  account  of  retention,  which  is  fre- 


POISONING  BY  VEGETABLE  ALKALOIDS,  ETC.  619 

quently  present,  but  to  prevent  reabsorption  of  the  atropine  from  the 
bladder. 

Cocaine. — The  alkaloid  of  Erythroxylon  coca  is  employed  in  medicine 
in  the  form  of  hydrochlorate.  It  is  used  as  a  local  anaesthetic,  particu- 
larly for  mucous  surfaces,  as  it  acts  upon  the  peripheral  terminations 
of  sensory  nerves.  Like  caffeine,  it  removes,  when  taken  internally,  the 
sense  of  muscular  fatigue.  Most  cases  of  cocaine  poisoning  have  arisen 
from  the  application  of  the  alkaloid  to  mucous  membranes.  Alarming 
symptoms  have  sometimes  suddenly  shown  themselves  in  patients  when 
in  the  dentist's  or  laryngologist's  chair,  owing  to  cocaine  having  been 
injected  into  their  gums,  or  when  employed  as  a  spray  to  the  throat. 
The  symptoms  are  nervous  excitement,  followed  by  a  very  rapid 
pulse  and  extreme  difficulty  of  breathing,  during  which  the  individual 
becomes  markedly  cyanosed,  and  the  pulse  so  feeble  as  to  be  almost 
imperceptible,  coldness  of  the  extremities,  and,  if  the  dose  has  been  large, 
convulsions,  coma,  and  death,  from  apnoea  or  syncope.  The  most  frequent 
and  alarming  symptom  is  altered  respiration,  but  the  drug  apparently 
operates  seriatim  upon  cerebrum,  medulla,  and  spinal  cord.  Cocaine 
acts  with  extreme  rapidity — it  has  caused  death  within  one  minute. 
Severe  and  rapid  as  the  symptoms  usually  are,  there  is  hope  of  ultimate 
recovery  if  the  patient  survive  half  an  hour.  A  very  small  dose, 
administered  hypodermically,  e.g.  -^  gr.,  or  if  applied  locally  |  gr.,  may 
cause  death ;  but  recovery  may  follow  such  large  doses  as  3  or  4  grs.,  if 
the  cocaine  has  been  taken  by  the  mouth  in  solid  form.  There  are  no 
characteristic  post-mortem  appearances  observed  in  this  form  of  poisoning. 

Nicotine  or  tobacco  poisoning,  although  an  extremely  fatal  poison, 
has  caused  very  few  deaths.  The  symptoms  are  giddiness,  exhaustion, 
tremor,  nausea,  vomiting,  feeble  circulation,  and  fainting,  difficult  breath- 
ing, accompanied  by  convulsions  and  followed  by  coma,  death  taking 
place  by  apnoea,  the  heart  beating  after  the  breathing  has  ceased. 
Formerly  tobacco  juice  and  leaves  used  to  be  applied  to  ulcers,  but  violent 
and  even  fatal  symptoms  are  known  to  have  followed  their  application. 
Such  symptoms,  too,  were  observed  after  the  administration  of  tobacco 
infusion  by  enemata  given  to  patients  suffering  from  dislocations,  in  the 
days  before  chloroform,  to  overcome  muscular  spasm.  Many  people  have 
a  marked  intolerance  of  tobacco.  In  the  act  of  smoking,  nicotine  is 
developed ;  by  far  the  largest  part  of  this,  however,  is  destroyed,  and  its 
place  taken  by  less  harmful  products  of  combustion,  such  as  the  pyridine 
bases,  otherwise,  unpleasant  symptoms  would  be  much  more  frequent. 
Pyridine  was  found  by  Hare  to  be  a  respiratory  paralysant  and  depressor 
of  the  spinal  cord.  Less  than  a  grain  of  pure  nicotine  has  caused  death. 
There  are  no  characteristic  post-mortem  appearances.  In  addition  to  the 
general  treatment,  it  may  be  necessary  to  maintain  respiration  by  elec- 
tricity and  the  inhalation  of  oxygen. 

With  the  impairment  of  vision  consequent  upon  tobacco-smoking, 
medical  men  have  long  been  familiar.  The  central  field  of  vision  is  prin- 
cipally affected,  causing  colour-blindness  for  red  and  green.  Tobacco  has 
a  special  preference  for  the  optic  nerve,  and  especially  for  its  peripheral 
terminations.  In  some  patients,  Judson  Bury  has  observed  loss  of  power 
in  fingers  and  wrists,  accompanied  by  loss  of  cutaneous  sensibility.  He 
is  inclined  to  regard  tobacco  as  capable  of  inducing  peripheral  neuritis. 
Considerable  discrepancy  prevails  as  to  the  quantity  of  tobacco  necessary 
to  produce  deleterious  effects.     De  Schweinitz  is  correct  when  he  says 


620       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

much  depends  not  only  upon  the  quantity,  but  also  upon  the  quality,  of 
the  tobacco,  the  idiosyncrasy  of  the  patient,  and  the  relation  of  the  smoking 
to  the  taking  of  meals,  the  effects  being  more  likely  to  be  induced  on  an 
empty  stomach,  and  especially  if  the  tobaeco  smoke  is  inhaled.  Trench 
tobacco  contains,  according  to  Schlosing,  5  to  8  per  cent,  of  nicotine, 
Virginian  tobacco  6  to  7  per  cent.,  Maryland  and  Havana  2  per  cent. 
Turkish  tobacco  is  said  to  contain  only  from  075  to  1*25  per  cent,  of  nicotine. 

Morphine  is  the  most  important  of  the  several  alkaloids  obtained 
from  Pcvpaver  somniferum.  It  is  a  strong  narcotic.  All  the  alkaloids — 
morphine,  codeine,  narcotine,  paverine,  and  thebaine — are  combined  in 
opium  with  meconic  acid.  These  alkaloids  are  not  all  alike  in  their  action- 
Some,  like  morphine,  have  a  narcotising  action,  namely,  narceine,  codeine, 
and  papaverine ;  whilst  others,  such  as  thebaine  and  narcotine,  exercise  a 
convulsant  influence.  Morphine  is  usually  regarded  as  having  from  four  to 
six  times  the  activity  of  opium  ;  besides,  it  is  more  soluble  in  the  secretions 
of  the  stomach.  Shortly  after  its  absorption  the  individual  becomes  some- 
what dizzy,  and  is  seized  with  an  irresistible  inclination  to  sleep.  The 
nervous  system  is  profoundly  affected ;  the  respiratory  centre  is  deranged, 
judging  from  the  slow  and  laboured  breathing,  which  may  be  not 
more  than  two  or  three  times  to  the  minute ;  the  pulse  is  feeble ;  the 
pupils,  at  first  extremely  contracted,  may  dilate ;  the  intellect  is  confused ; 
and  there  is  mental  stupor,  which  deepens  and  is  accompanied  by  increas- 
ing muscular  weakness.  Respiration  becomes  more  difficult,  and  finally 
ceases,  although  the  fatal  termination  frequently  comes,  and  quite  unex- 
pectedly too,  from  cardiac  failure.  Symptoms  of  poisoning  may  show 
themselves  shortly  after  morphine  has  been  taken,  or  they  may  be  delayed 
for  an  hour  or  two ;  but  once  they  appear  the  tendency  is  for  them  to 
increase  in  severity.  One  grain  of  morphine  taken  by  the  mouth  has 
caused  death,  and  ^  gr.  administered  hypodermically  has  caused  serious 
symptoms.  As  the  drug  is  one  toward  which  people  exhibit  a  varying 
idiosyncrasy,  the  symptoms,  both  as  regards  the  time  of  their  appearance 
and  severity,  will  be  largely  influenced  by  the  susceptibility,  vigour, 
and  good  health  of  the  individual.  Apoplectic  and  uramiic  coma,  acute 
alcoholism,  and  poisoning  by  chloral  and  other  narcotics,  may  be  mistaken 
for  morphine  poisoning.  Sometimes  it  is  extremely  difficult  to  differentiate 
one  from  the  other.  The  history  of  the  case,  and  the  finding  of  a  bottle 
that  has  contained  morphine,  the  extremely  contracted  pupils,  the  odour  of 
the  breath  and  the  rapid  development  of  symptoms  in  the  absence  of 
signs  of  ill  health,  are  a  help  in  the  diagnosis,  though  not  infallible  guides. 
There  are  no  post-mortem  signs  characteristic  of  morphine  poisoning.  As 
regards  the  other  alkaloids  obtained  from  opium,  codeine  resembles 
morphine  in  its  action ;  narceine  is  a  hypnotic ;  narcotine,  in  addition  to 
being  slightly  hypnotic,  is  strongly  convulsant ;  whilst  thebaine  causes 
convulsions,  and  is  therefore  not  unlike  strychnine  in  its  action.  It  is 
owing  to  the  numerous  alkaloids  which  the  crude  drug  contains  that  opium 
has  such  a  complicated  action  upon  the  body. 

Strychnine.  —  Most  organic  compounds,  when  treated  with  sul- 
phuric acid,  are  so  destroyed  that  they  can  be  no  longer  identified;  but 
it  is  characteristic  of  strychnine  that  it  resists  the  action  of  this  acid. 
This  circumstance  affords  a  valuable  means  for  separating  strychnine 
from  other  organic  substances.  The  alkaloid  has  an  extremely  bitter 
taste.  It  can  be  tasted  in  70,000  parts  of  water.  Symptoms  usually 
appear  within  ten  minutes  after  a  toxic  dose  has  been  taken ;  but  these 


POISONING  BY  VEGETABLE  ALKALOIDS,  ETC.  621 

may  be  deferred  if  the  stomach  contains  food,  or  they  may  appear  very 
early  if  the  drug  has  been  administered  hypodermically,  when  \  gr.  may 
prove  fatal.  It  is  stated  that  if  a  patient  suffering  from  strychnine 
poisoning  survive  three  to  four  hours,  his  chance  of  recovery  is  good ; 
but  this  cannot  altogether  be  relied  upon,  for  death  has  supervened 
eighteen  hours  after  the  development  of  the  symptoms.  It  is  difficult 
to  say  what  is  the  action  of  strychnine  upon  the  system,  but  it  seems  to 
heighten  the  reflex  excitability  of  the  spinal  cord  by  reducing  the  resistance 
in  the  paths  along  which  impulses  travel,  so  that  on  the  slightest  sensory 
impression  being  made,  for  example,  simply  touching  the  bedclothes, 
the  individual  is  thrown  into  a  tetanic  convulsion  amounting  at  times  to 
opisthotonos,  the  legs  being  extended,  the  feet  arched,  and  the  head  thrown 
violently  backwards,  so  that  the  body  practically  rests  upon  the  heels  and 
occiput.  The  respiratory  muscles,  too,  are  thrown  into  such  a  state  of 
spasm  that  breathing  becomes  impossible;  whilst  the  feeble,  irregular 
pulse,  dilated  pupils,  and  cyanotic  face  indicate  the  extent  to  which 
aeration  of  the  blood  is  checked.  Once  the  convulsion  has  subsided,  and 
the  muscles  have  become  relaxed,  the  body  is  found  to  be  covered  with 
cold  perspiration,  and  the  patient,  overcome  by  exhaustion,  falls  asleep. 
After  a  varying  interval,  the  convulsive  paroxysms  reappear.  Eeflex 
excitability  is  so  heightened  that  a  loud  sound  or  a  touch  may  cause  a 
convulsion;  and  as  the  intellect  remains  clear,  the  patient,  conscious  of 
the  terrible  ordeal  he  has  passed  through,  and  dreading  its  repetition, 
pleads  anxiously  for  relief.  Death  frequently  takes  place  during  a 
convulsion. 

With  the  exception  of  tetanus,  there  is  no  disease  that  exactly 
simulates  strychnine  poisoning,  although  in  courts  of  law,  epileptic, 
ursemic,  and  puerperal  eclamptic  convulsions  have  been  suggested  as 
resembling  it.  There  are  few  medical  practitioners  who  would  mistake 
either  of  these  for  strychnine  poisoning.  So  far  as  tetanus  is  concerned, 
there  is  usually  the  history  of  an  injury ;  and  besides,  tetanus  is  usually 
slowly  developed,  is  gradually  progressive,  and  has  nothing  of  the  acute 
urgency  of  symptoms  about  it  so  characteristic  of  the  alkaloidal  poison- 
ing. In  tetanus,  too,  it  is  the  muscles  of  the  back  of  the  neck  and  jaw 
that  are  first  affected,  giving  rise  to  the  characteristic  "  sardonic  grin " ; 
whereas  in  strychnine  poisoning  the  muscles  of  the  extremities  are  first 
affected,  and  the  muscles  of  the  neck  and  jaw  last.  In  tetanus,  in  addition, 
there  is  a  greater  tendency  for  rigidity  to  persist  between  the  spasms. 
Some  writers  maintain  that  the  temperature  is  higher ;  but  this  latter  is 
not  a  reliable  sign.  The  only  post-mortem  sign  of  value  in  strychnine 
poisoning  is  the  continued  rigidity  of  the  muscles,  which  lasts  for  a 
lengthened  period.  If,  along  with  this,  there  are  signs  of  congestion  of 
the  brain  and  spinal  cord,  with  subarachnoid  effusion,  the  diagnosis  of 
strychnine  poisoning  is  corroborated. 

Digitalin. — When  acted  upon  by  dilute  hydrochloric  or  sulphuric  acid, 
it  decomposes,  forming  a  glucose ;  hence  it  is  sometimes  spoken  of  as  a 
glucoside.  The  therapeutical  properties  of  the  plant  Digitalis  purpurea 
depend  upon  digitalin  and  digitoxin,  and  of  these  the  former  is  the  more 
important.  It  slows  the  action  of  the  heart,  and  in  toxic  doses  may  arrest 
it  in  diastole.  In  medium  doses,  it  at  first  accelerates  and  then  retards 
the  beat  of  the  heart ;  it  causes  contraction  of  the  arterioles,  and  thereby 
raises  the  blood  pressure.  To  some  people  digitalis  in  the  form  of  tincture 
or  infusion  is  an  irritant  poison;   it  causes  severe  pain  in  the  stomach, 


622       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

accompanied  by  vomiting  and  purging.  By  means  of  the  hypodermic 
injection  of  digitalin,  these  unpleasant  effects  can  be  avoided. 

Treatment. — Aconitine. — If  seen  early,  use  of  stomach  pump, 
emetics,  tannic  acid,  or  vegetable  infusions,  with  or  without  potassium 
iodide.  Cardiac  and  alcoholic  stimulants,  friction  of  the  skin,  hypodermic 
injections  of  digitalin,  and  maintenance  of  the  body  temperature  by  ex- 
ternal heat. 

Cocaine. — In  addition  to  the  treatment  laid  down  generally,  we  must 
combat  depression  by  alcoholic  stimulants,  or  by  ammonia  administered 
by  the  mouth,  rectum,  or  hypodermically.  Inhalations  of  nitrite  of  amyl,  or 
of  oxygen,  must  be  given  to  relieve  asphyxia ;  and  should  the  breathing 
cease,  artificial  respiration  or  the  application  of  electricity  must  be 
resorted  to. 

Morphine. — It  is  advisable  to  wash  out  the  stomach,  so  as  to  remove 
any  of  the  drug  that  has  not  been  absorbed,  even  though  emetics  may 
previously  have  been  administered  and  vomiting  occurred.  The  addition 
of  permanganate  of  potassium  to  the  water  for  lavage  (1  per  cent,  solution), 
has  proved  extremely  successful.  After  the  viscus  is  thoroughly  cleared 
out,  hot  strong  coffee  may  be  carried  in  by  the  stomach-pump,  and  allowed 
to  remain  therein.  To  prevent  sleep,  the  patient  must  be  kept  walking 
about,  care  being  taken  not  to  push  muscular  exertion  to  the  extent  of 
exhaustion,  nor,  on  the  other  hand,  too  readily  to  give  way  to  the  imploring 
requests  of  the  patient  to  be  allowed  to  sleep.  The  breathing  must  be 
watched,  and  increasing  feebleness  met  by  artificial  respiration,  which  may 
have  to  be  persisted  in  for  a  considerable  time,  two  to  three  hours  or 
even  longer.  Morphine  and  opium  particularly  paralyse  the  activity 
of  the  respiratory  centre.  Its  automatism  is  destroyed.  The  centre 
will  respond,  however,  to  the  influence  of  artificial  respiration.  If 
this  can  be  maintained  for  some  hours,  breathing  again  becomes  auto- 
matic. Stimulants,  alcoholic  and  ethereal,  will  be  required,  if  there 
is  flagging  of  the  circulation ;  also  the  subcutaneous  injection  of  atropine, 
w  ^°  "ro"  gr->  which  may  be  repeated  thrice  within  the  hour  if  necessary. 
Inhalation  of  oxygen  and  the  application  of  electricity  may  be  employed  ; 
but  where  life  is  threatened,  there  is  nothing  that  is  more  likely  to  prove 
successful  in  averting  death  than  artificial  respiration,  kept  up  by  relays  of 
assistants,  for  several  hours,  until  the  poison  is  to  some  extent  excreted 
from  the  system.  The  catheter  should  be  passed  from  time  to  time  to 
prevent  reabsorption.  Renewed  lavage  of  the  stomach  may  be  necessary, 
as  by  its  mucous  membrane  the  poison  is  largely  eliminated  from  the 
blood,  only,  however,  to  be  reabsorbed  if  the  contents  are  not  removed. 

Strychnine. — If  the  drug  has  been  swallowed,  give  emetics,  or  use 
the  stomach-pump.  Should  convulsions,  however,  have  developed,  it  may 
be  necessary  to  administer  chloroform,  so  as  to  allow  of  the  stomach  being 
washed  out.  Chloral  may  be  administered.  Asphyxia  may  be  warded  off 
by  inhalations  of  oxygen.  Absolute  quietude  in  the  room  and  house  gener- 
ally is  essential,  and  the  patient  should  be  touched  and  handled  as  little 
as  possible. 

Digitalin. — When  an  overdose  has  been  taken,  in  addition  to  the 
general  lines  of  treatment  already  mentioned,  the  administration  of 
stimulants  is  called  for  to  counteract  the  depression ;  also  warmth 
to  the  surface,  rest  in  the  recumbent  position,  and  opium  to  relieve 
pain.  A  hypodermic  injection  of  strychnine  or  of  some  stimulant  may 
be  administered,  if  the  heart  is  failing. 


POISONING  BY  GRAIN,  ERGOTISM,  PELLAGRA.  623 


POISONING   BY   GEAIN,  EEGOTISM,  AND   PELLAGEA. 

Etiology. — Ergot  is  a  drug  of  vegetable  origin,  belonging  to  the  class 
known  as  oxytoxics,  i.e.,  remedies  which  excite  uterine  action  during  or  after 
parturition.  It  is  a  blackish  body — 1  in.  in  length — grooved  on  one  side 
and  generally  curved.  On  microscopical  examination,  ergot  is  found  to  be 
composed  of  cells  rich  in  oily  matter,  but  wanting  in  starch.  The  origin 
of  the  word  ergot  is  doubtful.  It  was  originally  written  "  argot."  In  the 
French  dictionary  ergot  is  translated,  "  the  spur  of  a  cock  or  the  claw  of  a 
dog."  More  than  likely  it  is  from  its  resemblance  to  a  cockspur  that  the 
ergot  of  rye  received  its  name.  Its  true  nature  was  long  unknown,  but 
Tulasne  clearly  demonstrated  its  relationship  to  vegetable  fungi,  and  to  his 
work  it  may  be  said  little  has  since  been  added  regarding  the  botany  of  ergot. 
There  are  two  stages  in  the  life  of  a  fungus.  In  the  first  a  fungus  exists 
as  a  mycelium  or  a  filamentous  structure,  and  in  the  second  as  a  thallus  or 
ordinary  fungus,  which  perishes  shortly  after  having  brought  to  maturity  its 
reproductive  bodies.  Between  these  two  stages  in  certain  fungi  there  is  an 
intermediate  one,  in  which  the  plant  exists  as  a  sclerotium.  The  genus 
Claviceps  comprises  many  fungi  which  develop  in  the  pistils  of  the  various 
species  of  the  graminese  or  grasses.  Each  of  the  dark  bodies  familiarly  known 
to  us  as  ergot  is  the  sclerotium  of  the  Claviceps  purpurea,  which  infests  the 
grain  of  Secale  cereale,  or  rye.  In  a  spikelet  of  rye  or  wheat  that  is  becoming 
infested  with  the  fungus,  a  sticky,  sweet,  but  malodorous  exudation  is 
observed  trickling  from  one  of  the  flowers.  It  contains  sugar,  and,  like 
other  products  arising  from  the  irritation  of  vegetable  tissue  by  fungi,  is 
known  as  "  honey  dew,"  a  substance  extremely  attractive  to  ants  and  beetles, 
but  avoided  by  bees.  Once  "  honey  dew  "  appears  on  rye,  ergot  is  sure  to 
follow,  for  shortly  afterwards  there  is  observed  at  the  base  of  the  pistil  a 
flocculent  mass  of  mycelial  filaments,  which  in  their  growth  invade  all 
parts  of  the  ovary  and  pistil,  ultimately  forming  an  irregular  dark  body,  a 
sclerotium  that  finally  develops  into  commercial  ergot.  Most  of  the  ergot 
used  in  medicine  comes  from  Eussia  and  Spain.  Ergot  is  itself  liable  to  be 
invaded  by  an  acarus ;  this  insect  may  so  destroy  the  whole  of  the  interior 
that  it  leaves  simply  a  shell  filled  with  excrement.  The  ergot  used  hi 
medicine  is  the  blight  that  has  developed  upon  rye,  but  this  blight  is  found 
also  upon  wheat  and  other  cultivated  grains.  The  ergot  of  wheat  differs 
from  that  of  rye  in  being  shorter  and  thicker,  but  it  possesses  almost  equal 
medicinal  properties.  Ergot  contains  nearly  35  per  cent,  of  oily  matter,  and 
an  ammoniacal  base  known  as  trimethylamine.  It  is  not  definitely  known 
upon  what  its  activity  depends.  Ecboline,  ergotinine,  and  ergotine  are  the 
alkaloids  that  have  been  obtained  from  it ;  in  addition,  there  are  ergotinic, 
sphacelinic,  and  sclerotinic  acids.  The  watery  extract,  ergotine,  contains  in  a 
condensed  form  the  activities  of  the  drug.  Kobert,  who  has  given  consider- 
able attention  to  this  subject,  is  of  opinion  that  sphacelinic  acid  and  a 
substance  he  calls  cornutin  are  the  poisons  present  in  ergot. 

Pathology  and  symptoms. — Two  varieties  of  ergotism  have  been 
described — the  gangrenous  and  the  spasmodic.  The  symptoms  observed  in 
the  Paris  epidemic  of  gangrenous  ergotism  in  1828  were  itchiness  of  the 
skin,  vomiting,  giddiness,  abortion  amongst  pregnant  women,  arrest  of  the 
mammary  secretion  of  suckling  women,  pains  in  the  limbs,  diarrhoea, 
erythema  of  the  skin,  ecchymoses  or  bulla?,  numbness  and  tingling  of  the 
extremities,  succeeded   by  anaesthesia,  paralysis,  and  gangrene,  sometimes 


624       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

dry  at  other  times  moist,  which  destroys  the  part  affected.  In  spasmodic 
ergotism,  the  severer  cases  presented,  in  addition  to  many  of  the  symptoms 
just  enumerated,  painful  contractions  of  the  limbs,  passing  into  tetanus,  and 
followed  by  opisthotonos.  During  the  intervals  of  relaxation  there  were 
epileptic  paroxysms,  delirium,  complete  or  incomplete  blindness,  and  loss  of 
consciousness.  Many  of  these  symptoms  persisted,  and  left  the  individual 
either  insane  or  idiotic  for  life.  In  ergotism  the  pathological  changes 
are  found  principally  in  the  blood  vessels.  Eecklinghausen  found 
hyaline  thrombi  in  the  arterioles  and  capillaries,  the  arterial  walls  thick- 
ened and  undergoing  hyaline  degeneration.  Thoma  states  that  the 
gangrene  of  ergotism  is  preceded  by  sensory  and  vasomotor  disturbance ; 
hence  the  pallor  of  skin,  succeeded  by  reddening ;  the  presence  of  vesicles 
that  become  pustular ;  and,  finally,  gangrene  of  the  extremities,  owing  to 
persistent  contraction  of  the  small  arteries,  a  contraction  attributed  by 
some  writers  to  the  action  of  sphacelinic  acid  present  in  the  ergot.  Kobert 
is  also  of  opinion  that  it  is  the  sphacelinic  acid  in  the  ergot  that  causes 
gangrene.  Griinfeld  fed  animals  with  the  acid,  and  he  found  in  cocks 
that  the  comb  soon  became  gangrenous,  that  in  hogs  the  ears  became 
gangrenous  and  fell  off,  and  that  the  skin  of  dogs  and  cats  also  became 
gangrenous.  At  the  post-mortem  examination  of  animals  poisoned  by 
ergot,  Krysinski  found  the  epithelial  lining  of  the  intestine  necrotic  in 
patches,  with  small  haemorrhages  in  the  mesentery.  The  only  changes 
observed  in  the  central  nervous  system  have  been  degenerations  in  the 
postero-lateral  columns  of  the  spinal  cord.  There  are  probably  cerebral 
changes  as  well,  for  only  thus  can  we  explain  the  convulsions  and 
the  other  phenomena  observed  in  spasmodic  ergotism,  phenomena  which 
Moxon  thought  resembled  the  paroxysms  of  tetany  observed  in  this 
country.  As  in  England  there  has  been  little  of  either  epidemic  or  sporadic 
ergotism,  we  shall  for  a  description  of  the  ergot  convulsion  simply  quote 
the  words  of  Eomberg :  "  The  hands  and  feet  are  attacked  by  cramp  of 
the  flexor  muscles ;  the  fingers  of  both  hands  are  bent  like  hooks,  the 
thumbs  being  pushed  under  the  fore  and  middle  fingers  in  an  oblique 
direction ;  the  wrist  is  strongly  curved  inwards,  so  that  the  hands  assume 
the  shape  of  eagle's  beaks ;  the  toes  are  doubled  under  the  sole  of  the  foot." 
Eayer,  who  witnessed  the  epidemic  in  Paris  in  1828,  described  the 
disease  as  acrodynia.  He  considered  that  it  closely  resembled  pellagra, 
and  that  it  was  due  to  unhealthy  cereals  and  ergotised  rye.  Ehlers  seeks 
to  establish  an  identity  between  the  local  asphyxia  observed  in  the 
extremities  in  Raynaud's  disease,  and  the  swelling,  coldness,  and  blueness 
of  ergotism.  He  quotes  one  of  Raynaud's  cases,  where  a  young  woman 
during  labour  received  23  grs.  of  ergot.  Three  days  afterwards  she 
suffered  from  irregularity  of  the  heart,  fainting,  and  purging.  "Within  three 
months  there  developed  cyanosis,  and  coldness  of  the  extremities  followed 
by  gangrene.  Obstetrical  ergotism  has  followed  even  smaller  doses.  The 
drug  when  administered  for  a  lengthened  period  has  caused  local  con- 
ditions in  the  extremities,  resembling  those  observed  in  Raynaud's  disease, 
also  degenerative  changes  in  the  myocardium.  In  my  own  practice  I 
have  observed  such  unpleasant  symptoms  as  vertigo,  general  numbness, 
staggering  gait,  muscular  paresis,  and  loss  of  speech,  in  women  who  had 
taken  ergot  to  check  metrorrhagia,  symptoms  which  gradually  disappeared 
on  discontinuing  the  use  of  the  drug.  In  addition  to  ergotism,  poisoning 
by  grain  may  occur  when  the  corn  is  not  properly  washed  or  cleansed 
before  being  ground.   Several  of  the  foreign  wheats  which  I  have  examined 


POISONING  BY  GRAIN,  ERGOTISM,  PELLAGRA.         625 

during  my  official  inspection  of  flour  mills  for  the  Home  Office,  were  found 
to  be  very  dirty,  especially  those  from  the  Kiver  Plate  and  Persia,  particularly 
the  latter,  which  frequently  contains  manurial  filth.  Owing  to  the  very 
effective  methods  of  cleansing  and  washing  wheat  which  we  now  possess, 
foreign  wheat  is  thoroughly  cleansed  of  all  such  impurities  before  it  is 
ground  into  flour,  so  that  there  is  no  danger  from  this  source.  All  sorts  of 
weeds  and  seeds  are  frequently  present  with  the  wheat  grains,  such  as 
cockle,  rye-grass,  and  ergot.  Lehmann  found  that  bread  baked  from  flour 
containing  more  than  \  per  cent,  of  cockle  was  unsuited  for  human  food, 
and  that  when  ergot  was  present  and  exceeded  -2  per  cent.,  that  it  might 
give  rise  to  unpleasant  symptoms. 

Although  scarcely  regarded  as  a  poison,  since  large  doses  may  be 
required  to  produce  symptoms,  it  is  yet  capable  of  causing  salivation, 
vomiting,  dilated  pupils,  hurried  respiration,  and  quickened  pulse,  staggering 
gait,  paraplegia,  and  sometimes  convulsions  and  death.  Man  responds  very 
unequally  to  poisonous  doses  of  the  drug.  Under  its  influence  pregnant 
women  have  aborted.  In  men  and  in  non-pregnant  women,  in  addition 
to  the  symptoms  just  mentioned,  it  has  caused  anaesthesia  of  the  surface, 
coldness  of  the  extremities,  and  paralysis  of  the  special  senses.  Its 
action  upon  the  uterus  has  been  known  to  the  European  peasantry 
for  more  than  two  hundred  years,  yet  it  was  only  in  the  early  part 
of  this  century  that  the  drug  was  formally  introduced  into  medicine  by 
Dr.  Stearns  of  New  York.  Ergot  acts  principally  upon  the  nervous 
system,  and  especially  upon  the  centres  that  regulate  the  circulation. 
Courhant  in  1827  advanced  the  opinion  that  the  drug  caused  spasm  of 
blood  vessels,  and  in  1870,  Holmes  demonstrated  under  the  microscope,  in 
the  web  of  a  frog  poisoned  by  ergot,  that  both  arteries  and  veins  were 
much  contracted,  a  fact  confirmed  by  other  experimenters  and  by  the 
ophthalmoscopic  examinations  made  by  Nicol  and  Mossop,  who  observed 
very  marked  contraction  of  the  retinal  vessels  in  man  after  administering 
the  medicine.  The  arterial  pressure  first  falls,  then  rises,  owing  probably 
to  stimulation  of  the  vasomotor  centre.  When  toxic  doses  are  adminis- 
tered, the  blood  pressure  falls,  owing  to  paralysis  of  this  centre.  The 
intestinal  musculature  is  contracted.  The  body  temperature  falls.  The 
action  of  ergot  medicinally  is  principally  upon  the  womb  and  small  blood 
vessels.  It  has  little  influence  upon  the  unimpregnated  uterus,  and  very 
little  directly  upon  the  uterine  fibre  itself.  It  is  supposed  to  operate  chiefly 
through  the  centres  in  the  lower  part  of  the  spinal  cord,  whereby  contraction 
of  uterine  muscular  fibre  is  first  induced,  and  then  tetanus.  Domestic 
cattle  are  said  to  be  specially  susceptible  to  ergot  poisoning.  Several 
epidemics  of  loss  of  calves  by  cows  have  been  traced  to  eating  ergotised 
grain,  while  guinea-pigs,  rabbits,  and  cats  are  also  known  to  have  aborted. 

Ill  health,  consequent  upon  the  ingestion  of  bread  made  from  blighted 
grain,  has  of  late  years  been  less  observed  than  formerly,  owing  to  improved 
methods  of  agriculture,  and  the  more  rapid  international  transit  of  farm 
produce.  During  the  past  centuries  there  have  occurred  several  epidemics 
of  gangrene  due  to  this  cause.  Under  the  names  of  the"holyfire"  of  antiquity, 
erysipelas  of  Greek  authors,  and  "  St.  Anthony's  fire  "  of  the  Middle  Ages, 
epidemics  are  described  which  are  now  considered  to  have  been  ergotism. 
For  a  recognition  of  ergotism  and  its  cause  we  are  indebted  to  Thuillier  and 
Tessier.  One  of  the  earliest  epidemics  occurred  in  857,  and  is  mentioned 
in  the  annals  of  the  convent  of  Xanthen  on  the  Ehine.  Nearly  a  hundred 
years  after,  a  similar  epidemic  broke  out  in  Paris.  Subsequently  Aquitania 
vol.  1. — 40 


626        DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 

was  so  severely  scourged  by  ergotism  that  40,000  people  died  from  "  an 
invisible  fire,  consuming  the  body  and  separating  from  the  trunk  the  mem- 
bers that  had  been  attacked."  As  the  cause  of  the  disease  was  unknown, 
it  was  regared  as  a  "visitation."  France  experienced  several  epidemics 
from  1090  onwards.  Frequent  civil  wars  and  Norman  invasions  had  so 
transformed  the  north  and  central  parts  of  France  and  destroyed  the 
population,  that  the  fields  were  no  longer  cultivated,  and  the  result  was 
starvation.  Other  countries  were  not  spared.  An  epidemic  at  Liineburg  in 
Germany  in  1581  caused  532  deaths.  The  epidemic  broke  out  in  West- 
phalia, where  it  was  known  as  spasmus  pestilentialis,  and  attributed  to  bad 
bread  and  improper  nourishment.  Thuillier,  who  was  physician  to  the 
Duke  of  Sully,  was  an  eyewitness  of  the  epidemic  as  it  ravaged  Sologne. 
It  was  he  and  the  Abbot  Tessier  who  published  the  first  scientific  account 
of  ergotism.  The  soil  is  described  as  having  been  wet;  vegetable  production 
scanty  and  diminutive  on  account  of  the  barrenness  of  the  ground  and 
coldness ;  the  people  were  much  reduced  in  health,  and  became  the  subjects 
of  intermittent  fever.  Thuillier  maintained  that  ergotised  rye  was  the 
cause  of  the  epidemic,  that  the  severity  of  the  illness  was  proportional  to 
the  amount  of  poison  taken,  and  that  the  malady  was  especially  prone  to 
appear  during  wet  summers  following  cold  winters.  In  order  to  convince 
others  that  ergot  of  rye  caused  gangrene,  he  administered  the  poisonous 
grain  to  several  animals,  which  were  killed  by  it,  an  experimental  demon- 
stration which  was  soon  afterwards  realised  in  nature  by  animals  dying 
wholesale  from  eating  poisoned  grain.  Bread  made  from  diseased  rye 
rendered  those  who  ate  it  liable  to  gangrene.  It  was  in  Sologne  that  the 
spoiled  grain  was  first  called  ergot.  During  1716  gangrene  appeared  in  the 
cantons  of  Lucerne,  Berne,  and  Zurich,  among  people  who  had  partaken 
largely  of  vitiated  grain.  Where  only  small  quantities  had  been  eaten,  the 
illness  was  limited  to  a  sense  of  weight  in  the  head,  numbness  of  the 
extremities,  and  a  form  of  drunkenness,  especially  in  those  who  had  eaten 
their  bread  hot. 

All  the  writers  of  last  century  agree  as  to  the  epidemics  having 
principally  attacked  the  poor,  and  that  at  the  time  the  crops  were  scanty. 
The  disease  frequently  appeared  at  the  close  of  long. wars  and  bad  seasons. 
So  great  was  the  scarcity  of  grain  then,  that  the  peasantry  were  sometimes 
compelled  to  eat  bread  made  of  acorns,  grape  seeds,  roots  of  ferns,  and  other 
herbs,  cooked  without  salt,  or  any  kind  of  seasoning.  As  late  as  the  early 
part  of  last  century  we  read  of  an  epidemic  in  Silesia,  treated  empirically 
by  means  of  lycopodium  seeds  and  human  blood  freshly  drawn.  The 
country  lying  between  Moscow  and  the  Volga  was  also  affected,  and  with 
such  severity  that  in  the  neighbourhood  of  Mjni  it  is  estimated  that 
20,000  people  died.  Civilisation  and  improved  methods  of  agriculture 
have  gradually  driven  ergotism  further  and  further  east,  to  countries  where 
localities  are  insalubrious  for  the  drying  and  winnowing  of  grain.  Ergotism 
becomes  gradually  unknown  wherever  grain  is  properly  dried.  As  there 
have  always  been  isolated  and  apparently  sporadic  cases  in  the  intervals 
between  epidemics,  Ehlers  is  of  opinion  that  such  diseases  as  acrodynia, 
Baynaud's  disease,  and  erythromelalgia  are  forms  of  mild  ergotism. 

Bye  bread  still  forms  the  staple  article  of  food  of  the  lower  classes  in 
many  parts  of  Europe,  particularly  in  Bussia.  At  the  end  of  the  harvest 
the  ergotised  grain  is  not  always  sufficiently  carefully  separated  from  that 
which  is  healthy,  and  the  result  is  that  the  bread  of  the  peasantry  nearly 
always  contains  a  small  quantity  of  the  mould.     After  a  wet  and  cold 


POISONING  BY  GRAIN,  ERGOTISM,  PELLAGRA.         627 

summer  the  rye  is  frequently  much  ergotised,  and  it  is  then  that  ergotism 
appears,  but  how  far  it  is  due  to  any  specific  action  of  ergot  it  is  difficult 
to  say.  Trousseau  and  Pidoux  regarded  the  epidemics  as  due  to  disordered 
blood  conditions,  consequent  upon  improper  and  insufficient  food,  and 
attributed  them  to  general  poverty  and  starvation,  for  if  ergot  is  adminis- 
tered to  people  living  under  normal  conditions  it  does  not  cause  gangrene. 

In  Lombardy  and  the  adjacent  countries  there  occasionally  prevails 
a  disease  known  as  'pellagra,  from  pelle  skin,  and  agro  rough,  because  the 
skin  becomes  inflamed  or  rough.  Fifty-six  thousand  cases  are  reputed  to 
have  occurred  in  Lombardy  alone  in  1881.  The  patients  presented  symptoms 
connected  with  the  skin,  digestive  organs,  and  nervous  system.  At  first  the 
skin  was  red,  painful,  and  swollen.  This  was  followed  by  loss  of  appetite, 
distaste  for  food,  and  by  diarrhoea ;  and  subsequently,  in  the  severe  cases, 
by  extreme  prostration,  delirium,  and  paraplegia.  Many  of  the  patients  died, 
and  at  the  autopsy  numerous  small  ulcers  were  noticed  on  the  skin,  and  in  the 
intestines.  On  microscojDial  examination,  degenerative  changes  were  found 
in  the  spinal  cord.  Paltauf  and  Heider  considered  the  illness  to  be  due 
to  the  ingestion  of  corn  meal,  infected  by  the  B.  maiclis  ctiboni  and  the 
B.  mesentericus  fuscus.  Vaughan  believes  that  the  germs  which  cause 
the  disease  produce  ptomaines,  which  alike  in  their  chemical  and  physio- 
logical reactions  resemble  strychnine,  and  cause  tetanic  spasms  in  animals. 
In  1 871,  Lombroso  demonstrated  that  from  mouldy  corn  meal  an  extract 
•could  be  obtained  which  produced  tetanic  convulsions.  He  named  it 
jjellagrocine,  a  complex  body  composed  of  several  ptomaines,  some  of  which 
produce  narcosis  and  paralysis,  while  others  induce  cardiac  and  respiratory 
failure.  Clifford  Allbutt,  in  his  account  of  pellagra,  shows  that,  like 
ergotism,  it  is  a  disease  of  the  poor,  and  clue  to  bad  maize.  It  is  a  form 
of  ptomaine  poisoning,  which,  in  addition  to  causing  erythema  and 
gangrene  of  the  skin,  induces  a  lesion  in  the  lateral  columns  of  the 
spinal  cord,  hence  the  paralysis  met  with  during  life. 

Diagnosis  and  prognosis. — The  diagnosis  of  epidemic  ergotism 
rests  upon  the  history  of  a  cold,  wet  summer,  blighted  grain,  and  the 
prevalence  of  the  symptoms  of  the  disease  chiefly  amongst  the  poor,  who 
are  known  to  have  been  eating  bread  made  from  diseased  rye  or  wheat ; 
of  sporadic  ergotism,  upon  the  presence  of  the  symptoms  already  detailed, 
along  with  such  facts  as  may  be  explained  by  arterial  ischaemia. 

When  ergotism  attacks  elderly  people  the  prognosis  is  naturally  graver, 
on  account  of  the  state  of  the  heart  and  arteries  incidental  to  age. 

Treatment. — When  the  disease  is  epidemic,  the  ravages  of  ergotism 
should  be  met  by  improving  the  character  of  the  food,  by  destroying  all 
bread  that  has  been  made  out  of  blighted  grain,  and  substituting  for 
it  bread  made  from  healthy  cereals.  General  and  local  warmth,  carefully 
applied,  if  the  extremities  are  numb  or  commencing  to  be  gangrenous ;  the 
administration  of  stimulants,  and  medicine  to  allay  gastro-intestinal 
irritation,  if  present.  Contracted  limbs  should  be  treated  by  massage  and 
electricity.  Amputation  of  the  gangrenous  extremity  must  be  resorted  to 
when  necessary. 


628       DISEASES  CAUSED  BY  CHEMICAL  SUBSTANCES. 


LATHYEISM. 

In  addition  to  ergotism  and  pellagra,  consequent  upon  eating  diseased 
grain,  Kobert  and  Cantani  have  drawn  attention  to  a  series  of  symptoms 
caused  by  eating  food  made  from  the  seeds  of  the  common  vetch  or 
chick-pea.  Like  ergotism,  the  disease  has  generally  appeared  after  a 
failure  of  the  wheat  crop.  This  was  the  case  at  Allahabad,  as  reported 
by  Irving.  Lathyrism  has  been  mostly  observed  among  the  peasantry  of 
Spain,  France,  and  Italy,  and  in  certain  parts  of  India.  It  assumes  the 
epidemic  form,  and  affects  principally  males,  in  whom  it  causes  a  trans- 
verse myelitis  attended  by  sensory  and  motor  paraplegia.  Occasionally  the 
paralytic  symptoms  disappear,  but  there  remains  a  degree  of  spastic  tabes 
with  heightened  tendon  reflexes.  Lathyrism  develops  quickly,  the  earliest 
symptoms  being  stiffness  of  the  limbs,  pain  in  the  back,  formication,  altered 
sensation,  and  spastic  gait.  Men  and  anhnals,  but  particularly  horses,  are 
affected  by  it.  Hogs  are  said  to  be  quickly  killed  by  eating  vetch,  and 
horses  suffer  from  paralysis  of  the  recurrent  laryngeal  nerve  requiring 
tracheotomy.  The  muscles  in  man  and  animals  have  been  found  to  have 
undergone  fatty  degeneration,  and  the  multipolar  cells  in  the  anterior 
horns  of  grey  matter  in  the  spinal  cord  to  have  become  diminished  in 
number  and  atrophied. 

It  is  not  exactly  known  upon  what  particular  substance  in  the  vetch 
the  poisoning  depends 

THOMAS  OLIVER 


SECTION    IY. 
ALIMENTARY    SYSTEM. 


DISEASES   OF   THE   MOUTH. 

The  mouth  is  subject  to  many  diseases,  several  of  which  are  due  to  local 
inflammation,  while  others  are  manifestations  of  a  general  disease,  such 
•as  syphilis.  Some  of  the  local  infections,  for  example,  diphtheria,  scarlet 
fever,  measles,  are  discussed  elsewhere. 

The  local  affections  which  occur  in  the  mouth  may  be  due  to  local 
causes,  with  a  predisposition,  in  some  cases,  due  to  the  general  condition  of 
the  body.  Numerous  bacteria  are  found  in  the  mouth.  Some  of  these  are 
taken  in  with  the  food  and  air,  and  increase  in  the  mouth  and  throat,  their 
growth  being  aided  by  the  presence  of  dirty  or  decayed  teeth.  Through 
the  mouth  also  comes  sputum  from  the  lungs,  and  in  this  way  a  patient 
with  pulmonary  tuberculosis  may  infect  the  mucous  membrane,  causing 
a,  tuberculous  ulcer.  Over  thirty  varieties  of  bacteria  have  been  found  in 
the  mouth  by  Miller  and  others.  Many  of  these  are  pathogenic — some 
are  unnamed.  The  pathogenic  micro-organisms  are  chiefly  the  Staphylo- 
coccus pyogenes  aureus  and  alius,  and  the  Streptococcus  pyogenes,  as  well 
as  the  micrococcus  of  sputum  septicaemia  (Diplococcus  pneumoniae),  and 
the  Micrococcus  tetragenus.  The  pus  micro-organisms  are  not  constantly 
found  in  the  mouth,  but  inasmuch  as  they  are  present  in  the  air  their 
occurrence  in  the  mouth  is  always  a  possibility.  One  fungus,  the  oidium 
albicans  (Saccharomyces  mycoderma),  is  found. 

Animal  parasites  also  occur  in  the  mouth  and  tongue,  such  as  hydatids, 
which  are  rare,  the  guinea  worm,  not  found  in  this  country,  and  the 
trichina  spiralis. 

STOMATITIS. 

Stomatitis  is  an  inflammation  of  the  mouth  produced  by  the  growth 
of  bacteria  and  by  various  irritants,  mechanical  and  chemical,  such  as 
boiling  water  and  corrosive  substances,  and  mercury  administered  internally. 
It  occurs  also  more  especially  in  children,  in  acute  specific  diseases,  like 
measles,  diphtheria,  acute  bronchitis,  and  scurvy ;  is  no  doubt  due,  in  these 
conditions,  to  a  predisposition  to  infection,  induced  by  a  lowering  of  the 
resistance  of  the  body  by  the  primary  disease. 


630  ALIMENTAR  Y  S  YSTEM. 


Cataeehal  Stomatitis. 


Stomatitis  is  sometimes  chiefly  a  catarrhal  condition.  There  is  gener- 
ally an  increased  secretion  of  mucus  by  the  glands,  with  diffuse  areas  of 
redness  and  some  swelling  of  the  mucous  membrane.  This  is  frequently 
accompanied  by  salivation,  and  the  lips,  as  well  as  the  mucous  membrane 
inside  the  mouth,  are  affected.  In  mercurial  stomatitis  there  is  profuse 
salivation,  with  swelling  and  sponginess  of  the  gums,  which  readily  bleed, 
and  may  ulcerate,  and  there  is  intense  fcetor  of  the  breath. 

In  ulcerative  stomatitis,  which  is  usually  observed  in  children,  there 
are  numerous  superficial  ulcers  of  the  mucous  membrane  of  the  mouth 
and  lips,  surrounded  by  a  zone  of  congestion,  and  accompanied  by  a 
thickening  of  the  mucous  membrane  generally.  The  mouth  is  open, 
and  dribbles  with  a  discharge  (which  is  partly  purulent,  partly  mucoid) 
as  well  as  with  saliva.  A  dirty  feeding-bottle  is  a  frequent  cause  of  the 
disease  in  infants.  In  some  cases  the  stomatitis  is  more  localised,  and 
arises  definitely  near  the  tartar  of  the  teeth.  This  form  consists  in  a 
slowly  spreading  ulceration  of  the  mucous  membrane,  which  may  pass  on 
to  the  lips,  and  lead  to  more  or  less  extensive  but  superficial  destruction. 
Such  cases  occur  chiefly  in  low  conditions  of  health,  such  as  pulmonary 
consumption,  and  in  this  case  the  smooth  ulcer  may  become  infected  by 
the  sputum,  and  a  tuberculous  ulcer  develop.  The  treatment  in  such  a 
condition  is  the  application  of  strong  antiseptics,  followed  by  boric  acid 
lotion,  and  when  it  becomes  tuberculous,  by  a  scraping  of  the  ulcer. 

Treatment. — Acute  stomatitis  is  readily  treated.  If  it  be  due  to 
mercury,  the  administration  of  the  drug  must  be  stopped.  In  all  cases  the 
other  treatment  is  similar.  The  mouth  must  be  kept  constantly  washed 
out  with  an  antiseptic  lotion,  such  as  warm  boric  acid  lotion,  or  a  dilute 
alkaline  lotion — bicarbonate  of  sodium  (5  grs.  to  the  ounce).  After 
washing  the  ulcer,  it  must  be  dried  by  a  piece  of  clean  linen.  The  parts 
which  are  most  ulcerated  may  be  treated  by  a  careful  application  of  a 
solution  of  mercuric  chloride  (1  in  2000),  the  ulcer  being  dried  after  the 
application.  Glycerin  and  borax  is  also  sometimes  useful.  In  some  cases, 
especially  in  the  ulcerative  stomatitis  of  children,  chlorate  of  potash  is  a 
specific;  the  mouth  being  washed  with  a  solution  (10  grs.  to  the  ounce), 
and  the  drug  administered  internally  in  doses  of  1  to  5  grs.  It  must  be 
remembered  that  chlorate  of  potash  produces  poisonous  symptoms  some- 
times, and  may  lead  to  hasmoglobinuria. 

Aphthous  Stomatitis 

Thrush  is  an  inflammatory  condition  of  the  mouth,  shown  by  local 
superficial  erosions,  and  produced  by  a  fungus  called  the  oidium  albicans. 
In  some  cases  it  seems  certain  that  the  infective  agent  is  not  the  oidium, 
but  various  forms  of  bacteria.  The  oidium  is  seen  in  the  form  of  hyphse 
and  spores,  mixed  with  the  epithelium  of  the  mouth  and  the  tongue.  It 
may  be  demonstrated  by  soaking  the  scrapings  of  the  aphthous  ulcer  in 
liquor  potassse. 

The  aphthous  ulcer  is  small,  one-eighth  to  one-fourth  of  an  inch  in 
diameter ;  it  is  surrounded  by  a  zone  of  congestion,  and  covered  by  a  white 
or  whitish  yellow  layer,  containing  the  fungus  with  the  epithelium.  The 
edges  are  but  slightly  raised,  and  the  base,  on  removing  the  covering,  is 


DISEASES  OF  THE  MOUTH.  631 

reddened.  The  ulcers  are  painful  and  tender,  and  lead  sometimes  to  a 
difficulty  in  chewing  the  food. 

Thrush  is  most  common  in  children,  but  it  is  observed  in  adults,  in 
association  with  digestive  disturbances,  and  in  the  later  stages  of  wasting 
diseases.  In  children  it  is  constantly  associated  with  gastro-intestinal 
disturbances.  Its  appearance  is  frequently  ushered  in  by  vomiting  and 
diarrhoea,  and  by  some  degree  of  fever,  due  to  the  intestinal  disturbance. 
It  may  be  associated,  in  these  cases,  with  ulceration  of  the  anus  or  inter- 
trigo ;  but  when  there  is  ulceration  of  the  anus,  these  cases  are  usually 
congenital  syphilis. 

Treatment.  —  The  treatment  of  thrush  is  that  of  the  intestinal 
disturbance.  The  administration  of  alkalies  or  bismuth,  or  mercury  and 
chalk,  and  the  local  application  to  the  ulcer  of  glycerin  and  borax,  or 
nitrate  of  silver  solution  (10  grs.  to  the  ounce),  or  solution  of  corrosive 
sublimate  (1  in  2000),  or  of  glycerin  of  carbolic  acid  (1  in  20). 

Gum-Boil. 

This  is  the  result  of  an  inflammatory  condition  of  the  gums,  secondary 
to  caries,  such  as  periostitis  of  the  root  or  abscess.  Not  much  need  be 
said  of  this  condition,  inasmuch  as  its  consideration,  as  well  as  that  of 
its  results,  namely,  alveolar  abscess,  belongs  to  the  domain  of  surgery. 
Alveolar  abscess  may  open,  according  to  its  situation,  on  to  the  cheek, 
into  the  mouth,  or  into  the  antrum.     The  treatment  is  surgical. 

Of  non-inflammatory  diseases  of  the  mouth  may  be  mentioned  ranula, 
a  cyst  which  is  formed  at  one  side  of  the  frenum,  which  is  painless  in  its 
growth,  and  does  not  develop  to  a  size  greater  than  that  of  an  almond.  It 
is  probably  either  a  retention  cyst  of  a  buccal  gland,  or  a  cyst  of  a  salivary 
duct.  Epulis,  which  is  a  fibroma  of  the  gum,  is  not  infrequently  met  with. 
The  treatment  of  these  conditions  is  surgical.  Cancrum  oris  is  described 
amongst  the  general  diseases. 

SIDNEY  MAKTIK". 


DISEASES   OF   THE   TONGUE. 

The  conditions  of  the  tongue  to  be  considered  are — (1)  affections  in 
which  there  is  an  actually  diseased  condition  present  in  the  tongue,  and 
(2)  changes  in  the  tongue,  showing  indications  or  signs  of  disease.  The 
tongue  itself  is  subject  to  ulcerations,  which  are  of  various  kinds,  either 
simple  or  specific  (syphilitic,  tuberculous,  or  cancerous). 

Chronic  inflammation  may  be  superficial  or  lead  to  the  formation  of 
chronic  abscess,  or,  as  in  other  cases,  to  a  thickening  of  the  surface  of 
the  tongue.  The  tongue  is  subject  also  to  hypertrophy  and  to  atrophy, 
secondary  to  conditions  of  the  central  nervous  system,  and  to  new  growths, 
either  simple  or  malignant,  as  well  as  to  dermoid  cysts. 


ULCEEATION. 

The    tongue   is   subject   to   various    forms   of    ulceration — traumatic, 
dyspeptic,  aphthous,  syphilitic,  tuberculous,  cancerous. 


632  ALIMENTARY  SYSTEM. 

Traumatic  Ulceration  of  the  Tongue 

■usually  results  from  a  decayed  tooth,  so  that  the  ulcer  most  frequently 
is  at  the  outside  of  the  tongue,  about  the  middle,  or  towards  the  anterior 
part.  It  is  first  shown  as  a  soreness  at  the  side  of  the  tongue,  and  on 
examination  an  ulcer  is  found,  not,  as  a  rule,  large  in  extent,  surrounded 
by  some  thickening  and  congestion.  Traumatic  ulcers  may  also  be  due 
to  injury,  following  a  bite  of  the  tongue  such  as  frequently  occurs  in  an 
epileptic  fit. 

The  treatment  of  traumatic  ulcer  of  the  tongue  is  by  removing  the 
cause,  for  example,  a  jagged  tooth,  and  by  applying  a  mild  antiseptic  wash 
to  the  mouth.  "When  the  ulcer  does  not  heal  readily,  the  application  of 
nitrate  of  silyer  is  of  great  service. 

Dyspeptic  Ulceration 

or  ulceration  in  association  with  diseases  of  the  stomach,  is  not  common 
on  the  dorsum  of  the  tongue;  it  is  more  frequently  observed  on  the 
under  surface,  and  on  the  gums  and  cheek.  It  is  a  superficial  ulceration, 
which  tends  to  spread  somewhat,  the  edges  being  very  slightly  thickened, 
and  the  base  even.  Such  ulcers  are  most  common  in  cases  of  diminished 
vitality  of  the  system,  associated  with  gastric  disturbances.  They  usually 
heal  when  the  patient  improves  in  general  health,  and  are  best  treated  by 
means  of  the  constant  application  of  boric  acid  solution,  and  the  occasional 
application  of  glycerin  of  carbolic  acid  (1  in  20)  or  of  tincture  of  benzoin. 

Syphilitic  Ulceration 

is  of  frequent  occurrence  in  the  tongue.  It  usually  occurs  in  the  initial 
stages  of  the  disorder,  and  is  seen  as  an  irregular  ulceration  on  the 
sides,  and  at  the  top  of  the  tongue ;  with  a  whitish  base  and  some  thicken- 
ing around.  As  in  other  syphilitic  ulcerations  of  the  mucous  membrane, 
there  is  frequently  cicatrisation  at  one  part  and  ulceration  at  another. 
Mucous  tubercles  may  also  be  present.  Sometimes  the  ulceration  spreads 
over  the  dorsum  of  the  tongue,  producing  eventually  much  scarring  and 
destruction  of  the  epithelium.  The  surface  of  the  tongue  may  in  these 
cases  be  very  irregular,  with  whitish  patches  of  fibroid  tissue  in  parts,  and 
red  and  glazed,  or  even  with  a  bluish  surface  at  other  parts.  Such  a 
condition  cannot  be  mistaken  for  anything  but  syphilis. 

Gumma  of  the  tongue  occurs  in  a  later  stage  of  the  disease,  as  a  mass 
in  its  substance.  It  is  usually  at  the  posterior  part.  The  swelling  is 
painless,  and  tends  to  ulcerate,  the  discharge  being  sanious. 

The  treatment  of  syphilitic  disease  of  the  tongue  is  that  of  the 
general  disease.  The  local  treatment  consists  in  the  application  of  nitrate 
of  silver  in  a  solid  form  to  the  ulcer,  and  of  a  wash  of  mercuric  chloride 
(1  in  5000),  or  of  mercuric  bicyanide  (2  grs.  to  the  ounce). 

Tuberculosis  of  the  Tongue 

as  a  primary  disease,  is  practically  unknown.  It  is  observed  in  the  later 
stages  of  pulmonary  tuberculosis,  and  is,  no  doubt,  due  to  the  infection  of 
a  crack  in  the  tongue  by  the  sputum  as  it  passes  through  the  mouth. 
The  ulcer  which  is  eventually  formed  is  irregular,  with  an  uneven  base, 
covered  by  somewhat  cheesy  matter,  and  with  whitish  thickened  edges. 


DISEASES  OF  THE  TONGUE.  633 

From  the  appearance  it  is  impossible  to  distinguish  it  from  gumma. 
The  diagnosis  is  made  from  its  association  with  pulmonary  tuberculosis, 
and  from  the  fact  that  it  does  not  yield  to  treatment  by  mercury.  It 
may  be  treated  by  the  application  of  cocaine  and  scraping,  or  by  the 
application  of  mercuric  chloride  in  solution,  and  the  mouth  washed  with 
a  solution  of  bicarbonate  of  soda  and  glycerin,  or  with  a  permanganate  of 
potash  solution. 

Cancerous  Ulceration. 

Cancer  of  the  tongue  occurs  in  the  form  of  squamous  epithelioma. 
It  originates  at  the  base  of  the  tongue,  usually  at  the  middle  or  at  one 
or  other  side,  and  is  characterised  by  a  gradual  infiltration  and  thicken- 
ing of  the  tongue  itself,  and  of  the  surrounding  parts.  Subsequently  it 
ulcerates,  an  irregular  ulcer  with  an  irregular  base  being  formed,  giving 
forth  a  sanious  discharge,  which  frequently  becomes  foetid.  In  its  early 
stage  it  is  difficult  or  impossible  to  distinguish  from  gumma ;  but  it  is 
not  diminished  by  the  use  of  mercury,  and  tends  rapidly  to  infiltra- 
tion, as  well  as  to  an  affection  of  the  glands  below  the  jaw.  The  treat- 
ment of  cancer  of  the  tongue  is  surgical. 


TUMOUES. 

The  other  forms  of  tumour,  besides  cancer,  that  occur  in  the  tongue  are 
papillomata,  which  occur  in  the  form  of  warts ;  fatty,  fibroid,  cartilaginous, 
and  bony  tumours ;  cavernous  angioma  or  nsevus,  as  well  as  mucoid  cyst, 
also  occurs.  But  little  need  be  said  of  these  growths.  They  are  all  slowly 
growing,  producing  but  little  or  no  pain ;  the  warts  and  fibrous  tumours 
project  from  the  surface,  while  the  others  are  in  the  substance  of  the  tongue. 
The  mucoid  cysts  are  usually  found  at  the  base  of  the  tongue,  and  project 
on  the  surface.  They  may  be  confounded  with  solid  tumours,  or  with  chronic 
abscess  ;  the  diagnosis  is  made  when  they  are  opened. 


INFLAMMATION. 

The  whole  of  the  tongue  may  become  inflamed,  as  when  a  powerful 
irritant  is  applied  to  it ;  for  example,  in  the  case  of  swallowing  corrosive 
poisons,  of  the  sting  of  a  wasp,  or  of  a  septic  wound  to  the  tongue.  Some 
cases  of  macroglossia  are  of  this  nature.  The  tongue  is  greatly  enlarged, 
jjainful  and  tender,  and  swallowing  becomes  impossible.  The  lips  are  also 
enlarged,  and  the  glands  below  the  jaw  become  affected.  The  treatment  of 
glossitis  is  surgical,  and  consists  in  the  making  of  incisions  in  the  tongue. 
Inflammation  of  the  tongue  may,  however,  be  more  limited,  so  that  only  a 
superficial  glossitis  results.  The  cause  is  still  an  irritant,  such  as  scalding 
or  a  corrosive  poison,  or  the  effects  of  the  administration  of  mercury.  The 
dorsum  is  the  part  chiefly  affected,  and  is  swollen,  reddened,  and  smooth, 
the  epithelium  being  more  or  less  cast  off.  By  the  use  of  warm  mouth 
washes  the  inflammation  subsides. 

Chronic  abscess  of  the  tongue  is  a  rare  condition,  and  usually  forms  a 
swelling  just  in  front  of  the  circum vallate  papillae.  It  is  of  slow  formation, 
and  has  thickened  edges,  and  sometimes  fluctuates.  The  condition  is 
treated  sur<ncallv. 


634  ALIMENTARY  SYSTEM. 

What  may  be  considered  as  a  chronic  inflammation  of  the  tongue  occurs 
in  the  form  of  leucoma  and  ichthyosis.  The  condition  is  usually  seen  in 
middle  age,  and  is  no  doubt  due  to  irritation  of  one  form  or  another.  In 
leucoma  there  are  white  patches  on  the  dorsum  of  the  tongue,  due  to  a 
thickening  of  the  mucous  membrane,  but  there  is  no  roughness  of  the 
surface. 

In  ichthyosis,  also  termed  psoriasis  or  keratosis,  but  better  known  as 
leucoplakia  buccalis,  the  dorsum  is  usually  affected,  and  there  is  great 
hypertrophy  of  the  papilla?,  giving  the  appearance  either  of  a  shaggy  coat 
or  of  the  rough  skin  of  a  fish.  In  some  of  these  cases  there  is  a  history  of 
syphilis,  with  other  cases  epithelioma  is  associated. 


ATEOPHY. 

Atrophy  of  the  tongue  occurs  as  the  result  of  lesions  of  the  central 
nervous  system,  or  of  the  hypoglossal  nerve.  In  the  latter  case  it  is  almost 
always  unilateral ;  in  the  former  case  it  may  be  unilateral  or  bilateral. 
The  diseases  in  which  it  is  usually  found  are  glosso-labio -laryngeal  palsy,  in 
which  the  nucleus  of  the  hypoglossal  nerve  is  affected,  disseminated  sclerosis 
or  tabes,  which  spreads  up  to  the  medulla.  Paralysis  in  these  cases  precedes, 
or  is  coincident  with,  the  atrophy,  and  the  movements  of  the  tongue  become 
greatly  limited. 

HYPEETEOPHY. 

Microglossia  occurs  as  a  congenital  defect,  and  is  associated  with  con- 
genital mental  deficiency.  It  is  frequently  associated  with  a  thickness  of 
the  lips  (macrocheiha),  so  that  the  patient  usually  has  protruding  lips, 
with  a  large  tongue  between,  and  an  idiotic  expression.  Saliva  dribbles 
from  the  mouth,  and  ulceration  of  the  tongue  and  lips  frequently  occurs, 
with  fcetor  of  the  breath.  This  condition  is  to  be  distinguished  from  the 
enlarged  tongue,  the  result  of  inflammation. 

The  Tongue  as  an  Index  of  Disease. 

Besides  the  local  diseases  to  which  the  tongue  is  subject,  and  the 
diseases  which  are  due  to  local  conditions,  the  tongue  may  be  affected  by 
general  diseases  of  the  body.  The  conditions  now  to  be  discussed  are  four 
in  number,  namely,  the  furring  of  the  tongue,  dryness  of  the  tongue, 
enlargement  of  the  papilla?,  and  flabbiness  of  the  tongue. 

Furring  of  the  tongue  occurs  in  many  different  conditions.  The  fur 
may  be  distributed  all  over  the  tongue,  or  only  at  the  back,  and  consists 
partly  of  epithelial  scales  and  partly  of  micro-organisms.  When  a  furred 
tongue  cleans,  the  fur  disappears  first  from  the  tip  and  edges,  and  last  of 
all  from  the  posterior  part.  Sometimes  it  cleans  uniformly,  at  other  times 
in  patches  or  flakes ;  the  fur  originally  may  have  been  in  patches,  giving 
rise  to  what  has  been  called  the  "  stippled "  tongue  (Dickinson).  The 
furred  tongue  may  be  associated  with  enlargement  of  the  fungiform  papilla?, 
and  this  enlargement  of  the  papilla?  may  persist  after  the  tongue  is  clean. 

The  rapid  cleaning  of  the  tongue,  with  denudation,  in  part,  of  the 
superficial  epithelium,  as  well  as  the  continued  enlargement  of  the  papilla?, 
gives  rise  to  the  red  and  raw  or  glazed  tongue ;  whereas  the  enlargement 
of  papilla?,  with  whitish  patches  in  between  (usually  at  the  tip),  gives  rise 


DISEASES  OE  THE  TONGUE.  635 

to  the  "  strawberry  "  tongue.  The  tongue  becomes  furred  in  local  diseases, 
such  as  inflammation  of  the  tonsils,  and  of  the  mouth  generally.  The  side 
on  which  the  inflammation  is  most  intense  is  more  furred  than  the  other  ; 
thus,  if  one  tonsil  is  more  inflamed  than  the  other,  that  side  of  the  tongue 
is  most  furred ;  similarly,  where  a  tooth  produces  inflammation  of  the 
tongue,  that  side  becomes  furred.  The  tongue  becomes  also  furred  from 
general  disease,  the  chief  of  which  is  the  condition  of  pyrexia.  In  all  acute 
fevers  this  is  the  case,  such  as  typhoid,  typhus,  rheumatic,  and  scarlet  fevers, 
variola,  and  many  others.  In  nervous  diseases  of  acute  onset  the  tongue 
also  becomes  furred,  such  as  in  the  epileptic  state,  in  apoplexy,  and  in 
neuralgia,  where  the  tongue  is  not  infrequently  furred  unilaterally,  that 
is,  on  the  side  of  the  pain.  In  diseases  of  the  stomach  the  tongue  is  furred 
in  acute  attacks  of  gastric  irritation  and  gastric  catarrh.  In  ulcer  of  the 
stomach  and  in  gastric  insufficiency  the  tongue  is  not  usually  furred,  and 
in  cancer  the  furring  is  variable.  In  acute  liver  conditions  the  tongue  is 
also  furred,  but  in  these  cases  furring  is  as  frequently  to  be  ascribed  to  the 
stomach  as  the  liver. 

The  broad,  pale,  flabby  tongue  is  the  tongue  of  anaemia,  of  Bright's 
disease,  and  of  wasting  diseases.  It  is  no  doubt  the  direct  result  of  the 
anaemia  produced  by  these  conditions.  In  Bright's  disease  the  tongue  may 
also  be  (Edematous. 

The  dry  tongue  is  due  directly  to  diminished  secretion  of  saliva,  as  well 
as  to  the  fact  of  sleeping  with  the  mouth  open.  A  condition  of  high  fever 
leads  to  dryness  of  the  tongue,  as  there  is  a  diminished  secretion  of  saliva. 
In  a  similar  manner,  an  increased  excretion  of  water  from  the  body  leads  to 
dry  tongue,  as  in  polyuria,  excessive  sweating,  and  profuse  diarrhoea.  To 
this  cause  must  be  ascribed  the  dry  tongue  which  occurs  not  infrequently 
in  cases  of  dilatation  of  the  stomach.  Dry  tongue  is  also  observed  in  cases 
of  bodily  prostration,  and  is  the  characteristic  tongue  of  nervous  people. 
What  may  be  called  "  a  nervous  tongue  "  is  pale,  usually  dry,  and  at  other 
times  covered  with  a  thin  froth.  The  dry  tongue  in  pyrexia  is  a  sign 
sometimes  of  high  temperature,  sometimes  of  great  bodily  prostration,  and 
is  a  symptom  which  must  always  be  looked  upon  as  somewhat  serious. 
One  of  the  signs  of  improvement  in  the  febrile  patient  is  when  the  dry 
tongue  becomes  moist,  as  it  does  in  the  period  of  defervescence  and  during 
the  administration  of  alcohol.  One  of  the  signs  of  alcohol  doing  good  in 
fevers  is  when  the  dry  tongue  becomes  moist  under  its  influence.  The  dry 
tongue  in  diabetes  becomes  moist  again  when  the  amount  of  sugar  in  the 
urine  greatly  diminishes.  Dry  tongue  and  xerostomia  in  gastric  irritation 
disappear  when  the  stomach  condition  is  relieved. 

Pityriasis  linguae  (annulus  migrans,  lichenoid)  is  a  curious  condition  of 
the  tongue,  sometimes  confined  to  one  side,  sometimes  present  all  over  the 
dorsum  and  the  under  surface  of  the  tongue.  It  occurs  in  the  form  of 
circles  or  curves,  which  are  whitish  in  appearance,  and  due  to  the  enlarge- 
ment and  the  cornification  of  the  papillae.  The  centre  of  the  curve  is  bare, 
and  the  papillae,  to  some  extent,  have  here  lost  their  epithelium  ;  the  tissue 
below  is  infiltrated  with  leucocytes.  It  is  evanescent,  the  eruption  coming 
and  going  without  obvious  cause.  Its  causation  is  unknown,  no  definite 
parasite  having  been  found  associated  with  it.  Treatment,  whether 
antiseptic  or  otherwise,  is  of  no  avail.  It  occurs  both  in  children  and 
adults,  perhaps  more  frequently  in  the  former;  it  has  been  observed  in 
children  who  have  but  slight  ailments,  but  it  may  be  associated  with  some 
severe  and  fatal  disease.  SIDXEY  MAETIiST. 


636  ALIMENTARY  SYSTEM. 


DISEASES   OF   THE   SALIVARY   GLANDS. 

The  secretion  of  the  three  pairs  of  salivary  glands  is  necessary  for  the 
moistening  of  the  food  and  for  the  initial  digestion  of  starch,  so  that 
changes  in  the  secretion  in  disease  are  of  some  importance. 


FUNCTIONAL  DISOEDEES. 

In  many  people  the  diastatic  action  of  the  saliva  is  from  time  to  time 
very  deficient ;  the  secretion  may  be  either  diminished  or  increased  in 
disease.  When  diminished,  it  produces  a  condition  which  is  called  xero- 
stomia, or  dry  mouth ;  when  increased,  it  produces  salivation,  saliva  filling 
the  mouth  and  running  from  the  corners  of  the  mouth.  Diminution  of  the 
secretion  occurs  in  inflammatory  conditions  of  the  mouth  (ptyalism),  in 
fever,  in  belladonna  and  stramonium  poisoning,  and  in  conditions  in  which 
there  is  increased  excretion  of  water  from  the  body,  such  as  in  profuse 
perspiration,  in  diabetes,  in  polyuria,  and  in  prolonged  diarrhoea.  The 
most  marked  cases  of  xerostomia,  as  well  as  the  most  prolonged,  are 
observed  in  certain  conditions  of  the  stomach,  such  as  those  associated 
with  a  hypersecretion  of  hydrochloric  acid.  The  treatment  of  xerostomia 
is  directed  to  the  relief  of  the  local  condition  by  the  use  of  glycerin  and 
borax,  or  by  a  continuous  washing  out  of  the  mouth  with  tepid  water 
without  swallowing  it.  In  cases  where  it  is  due  to  diabetes  or  a  stomach 
condition,  it  is  relieved  when  the  amount  of  sugar  diminishes  in  the  urine, 
or  when  the  stomach  condition  is  improved.  Increased  secretion  of  saliva 
may  occur,  either  from  the  reflex  or  direct  effect  on  the  salivary  glands 
which  is  produced  by  certain  drugs,  such  as  mercury,  iodine,  tobacco,  and 
pilocarpine.  It  also  is  produced  in  the  early  stages  of  local  inflammatory 
conditions  of  the  mouth,  in  excessive  cough  due  to  bronchitis  ;  and  it  has 
been  observed  also  as  the  result  of  emotions  and  pain,  and  in  pregnancy 
and  insanity.  The  treatment  of  ptyalism  or  salivation  is  in  some  cases 
possible,  in  others  futile ;  thus,  in  salivation  due  to  mercury,  pilocarpine,  or 
iodine,  the  condition  ceases  soon  after  the  cessation  of  the  drug.  In  that 
due  to  other  conditions,  small  doses  of  belladonna  may  be  employed  (10 
minims  of  the  tincture  three  times  a  day),  or  small  doses  of  pilocarpine  may 
be  administered. 

OEGANIC  DISEASES. 

The  diseases  to  which  the  salivary  glands  are  subject  are  mumps, 
inflammation,  new  growth,  calculus,  and  fistula  of  the  duct.  Inflammation 
is  usually  observed  in  the  parotid  gland  (parotitis).  It  is  a  manifestation 
of  pysemia  or  septicaemia  of  whatever  origin,  and  is  frequently  a  valuable 
sign  of  such  condition.  It  is  a  diffuse  inflammation  of  the  gland,  which 
frequently  ends  in  suppuration,  either  in  one  abscess,  or  in  multiple 
abscesses  distributed  through  the  gland  tissue.  It  is  shown  by  a  swelling 
in  front  of  and  below  the  ear,  with  a  diffuse  swelling  of  the  cellular  tissue 
around.  The  swelling  is  very  painful  and  extremely  tender,  and  ks 
appearance  may  be  ushered  in  by  a  rigor,  and  an  increase  of  the  fever 
caused  by  the  primary  disease. 

Salivary  calculi  are  like   those  which   are   formed   sometimes   in   the 


DISEASES  OF  THE  FAUCES  AND  TONSILS.  637 

pancreas.  They  are  present  in  the  ducts  of  the  gland,  and  are  composed 
of  carbonate  and  phosphate  of  lime.  Fistula  of  the  duct  occurs  sometimes 
as  the  result  of  a  calculus,  but  more  frequently  as  the  result  of  inflammation 
of  the  cheek,  whereby  the  duct  is  opened  to  the  exterior. 

The  new  growths  which  occur,  chiefly  in  the  parotid  gland,  are  fibroma, 
chondroma,  and  malignant  tumours.  Chondroma  forms  a  hard,  slowly 
growing  tumour,  unilateral,  and  extending  from  below  the  lobe  of  the  ear 
upwards  in  front  to  the  ear,  along  the  cheek.  A  malignant  tumour  has  a 
similar  position ;  it  grows  more  rapidly,  is  softer,  and  infiltrates  the  sur- 
rounding tissues,  as  well  as  affects  the  neighbouring  lymphatic  glands. 

SIDNEY  MARTIN. 


DISEASES   OF   THE   FAUCES   AND   TONSILS. 

The  tonsils  are  affected  by  various  diseases,  some  of  which  are  due  to  a 
definite  infection  by  micro-organisms ;  others  are  manifestations  of  a  general 
disease ;  others,  again,  are  local  non-infective  diseases.  Thus  the  tonsils 
may  be  involved  in  the  eruptions  of  varicella,  variola,  and  herpes,  and  are 
the  seat  of  inflammation  in  scarlet  fever,  measles,  and  certain  other  diseases 
to  be  discussed  under  "acute  tonsillitis."  They  are  also  implicated  in 
secondary  syphilis,  and  a  gumma  may  be  present  in  the  later  stages ;  it  is 
rarely  the  seat  of  tuberculous  infection.  Diphtheritic  infection  is  discussed 
elsewhere.  The  rashes  of  varicella  and  variola,  which  occur  in  the  fauces 
and  tonsil,  do  not  differ  from  the  rashes  of  the  skin,  and  need  not  be  further 
described.  The  same  may  be  said  of  herpes.  In  syphilis  condylomata 
occur,  which  are  more  or  less  transparent  projections  associated  with  serpi- 
ginous ulceration.  There  is  as  well  a  diffused  congestion  of  the  parts,  and 
the  distribution  of  the  condylomata  is  very  irregular. 

Tuberculous  ulceration  of  the  tonsil  is  very  rare,  and  is  usually 
associated  with  a  similar  ulceration  of  the  pharynx.  The  ulcer  has 
thickened  edges  and  an  irregular  base,  and  is  covered  by  white  or  whitish 
yellow  patches,  containing  tubercle  bacilli.  The  diagnosis  is  made  from 
the  great  chronicity  of  the  ulceration,  and  by  the  fact  of  its  association  with 
tuberculosis  of  the  lungs.  It  never  occurs  as  a  primary  disease,  and  is 
only  observed  in  the  later  stages  of  pulmonary  tuberculosis. 

Malignant  disease  of  the  tonsil,  whether  sarcoma,  lymphosarcoma,  or 
epithelioma,  is  characterised  by  the  same  appearances  remarked  on  in 
malignant  disease  elsewhere.  Thus  there  is  great  enlargement  of  the  parts, 
the  disease  being  at  first  always  unilateral,  and  extension  of  the  growth 
across  the  soft  palate,  and  to  the  cheek ;  while  the  glands  below  the  jaw 
become  enlarged,  the  enlargement  being  progressive,  and  leading,  not  infre- 
quently, to  adhesion  to  the  skin,  and  subsequent  ulceration.  Ulceration  of 
the  growth  on  the  tonsil  is  an  occurrence  leading  to  a  very  foetid  discharge. 
The  course  of  the  disease  is  progressively  downwards,  unless  a  radical 
operation  for  its  cure  has  been  performed  in  the  early  stage. 

The  diseases  which  are  to  be  more  fully  discussed  in  this  place,  are  those 
which  are  the  result  of  inflammation,  whether  acute  or  chronic,  namely, 
acute  tonsillitis,  follicular  tonsillitis,  and  chronic  tonsillitis  or  hypertrophy. 


638  ALIMENTAR  Y  S  YSTEM. 

ACUTE  TONSILLITIS. 

This  is  an  acute  parenchymatous  inflammation  of  the  tonsils  produced 
by  micro-organisms.  The  micro-organisms  which  have  been  found  are 
either  streptococci  or  staphylococci.  Sometimes  the  streptococcus  is  found 
by  itself,  more  commonly  it  is  mixed  with  the  staphylococcus.  There  may 
be  other  micro-organisms  which  produce  inflammation  of  the  tonsils,  such, 
for  example,  as  the  pneumococcus. 

Etiology. — Acute  tonsillitis  is  frequently  a  primary  disease,  being 
due  to  direct  exposure  to  infection.  Of  such  a  nature  is  the  tonsillitis 
which  follows  on  breathing  emanations  from  drains,  or  that  which  occurs 
in  hospitals  and  other  public  buildings,  where  there  are  large  numbers  of 
people  housed  with  deficient  ventilation  and  accumulation  of  dust.  The 
infection  is  either  associated  with  a  low  condition  of  vitality  of  the  patient, 
or  there  may  be  a  diminished  local  resistance,  as  when  acute  tonsillitis 
supervenes  on  chronic.  It  is  a  disease  usually  occurring  in  young  adults, 
whether  male  or  female,  and  is  most  frequent  in  children.  Acute  tonsillitis 
is  associated  with  other  diseases,  the  most  common  of  which,  perhaps,  is 
rheumatic  fever.  Infection  of  the  tonsils  by  bacteria  also  supervenes  in 
scarlet  fever,  in  diphtheria,  in  measles,  and  sometimes  in  whooping-cough, 
and  even  in  rheumatic  fever.  Cultivations  made  from  the  throat,  show 
that  the  condition  is  one  due  to  direct  infection  by  micrococci. 

Symptoms. — Acute  tonsillitis  is  sudden  in  its  onset,  being  associated 
at  first  with  a  tickling  in  the  throat  and  a  sense  of  heat,  and  perhaps  of 
dryness.  The  patient  rapidly  becomes  febrile,  the  temperature  rising  to  104° 
and  105°;  the  fever  being  associated  with  malaise  and  bodily  and  mental 
depression.  Headache,  frontal  in  character,  is  common,  and  the  patient 
takes  to  his  bed.  On  examination,  the  throat  may  be  found  in  varying 
conditions ;  the  tonsils  may  be  enlarged,  but  chiefly  congested,  as  are  the 
fauces  and  soft  palate.  The  colour  varies  from  reddish  to  purplish  red, 
and  the  surface  of  the  tonsils  is  frequently  covered  by  a  thin  exudation, 
dirty  yellow  in  colour,  which  consists  partly  of  mucus,  and  partly  of 
albuminous  secretion,  containing  large  numbers  of  micro-organisms.  The 
glands  below  the  jaw  are  enlarged,  and  surrounded  by  a  diffuse  swell- 
ing, which  is  tender  on  pressure.  There  is  at  this  time  great  difficulty 
and  pain  in  swallowing ;  the  tongue  is  thickly  covered  with  a  yellow  fur, 
and  the  breath  becomes  foul.  Constipation  is  present,  and  the  urine  is 
diminished  in  quantity  and  loaded  with  urates.  In  some  cases  the  tonsils 
do  not  present  the  appearances  described  above,  inasmuch  as  there  is 
more  exudation  on  the  surface.  This  exudation  may  be  patchy  in  nature, 
and  may  form  an  imperfect  membrane,  which  is,  as  a  rule,  readily  removed 
by  means  of  a  brush  dipped  into  a  solution  of  nitrate  of  silver  (10  grs.  to 
the  ounce). 

From  this  point  the  course  of  the  disease  varies  somewhat.  The 
duration  of  the  acute  symptoms,  if  the  treatment  carried  out  is  effective, 
is  from  four  to  five  days,  and  the  patient  is  usually  well  again  in  a 
fortnight.  In  some  cases,  however,  suppuration  occurs,  and  an  abscess  is 
formed  in  the  tonsil.  An  abscess  may  be  suspected  if  the  fever  keeps  up, 
and  if  the  swelling  is  very  great,  so  great  that  the  patient  can  hardly  open 
his  mouth ;  on  examination  with  the  finger,  the  tonsil  on  one  or  other  side 
is  found  soft  and  fluctuating.  The  abscess  sometimes  ruptures  spontane- 
ously into  the  mouth,  and  in  rare  cases  may  lead  to  profuse  haemorrhage. 
Abscess  of  the  glands  of  the  neck  also  occurs. 


DISEASES  OF  THE  FA  UCES  AND  TONSILS.  639 

Diagnosis. — The  diagnosis  of  acute  tonsillitis  is  to  be  made  chiefly 
from  diphtheria.  The  disease  also  may  be  distinguished  to  some  extent 
clinically  from  cases  of  follicular  tonsillitis. 

In  acute  tonsillitis  the  infective  agent  may  be  of  different  degrees  of 
virulence ;  infection  by  the  streptococcus  being  more  virulent  than  that  by 
the  staphylococcus,  and  the  micro-organisms  may  form  a  membrane  to  some 
extent  resembling  that  present  in  diphtheria.  On  the  other  hand,  although 
the  formation  of  membrane  is  the  rule  in  diphtheria,  it  may  be  absent  in  a 
mild  case,  congestion  or  enlargement  of  the  tonsils  or  fauces  alone  being 
present.  These  facts,  together  with  the  necessity  in  treatment  of  cases  of 
diphtheria  for  the  injection  of  antitoxic  serum,  render  the  diagnosis  between 
simple  tonsillitis  and  diphtheria  a  very  important  one.  It  is  in  many 
cases  impossible,  when  the  patient  is  first  seen,  to  decide  whether  some 
cases  are  really  diphtheria  or  not.  Such  cases  are  better  distinguished  as 
doubtful  ones,  and  by  some  are  erroneously  called  "  diphtheritic  throat," 
meaning  thereby  a  throat  like  that  of  diphtheria,  but  not  actual  diphtheria. 
This  nomenclature  is  very  misleading,  inasmuch  as  it  leads  to  the  non- 
employment  of  the  curative  agent  (antitoxic  serum)  in  a  certain  number  of 
cases  of  diphtheria,  which  may  be  fatal. 

A  large  proportion  of  these  doubtful  cases  is  readily  diagnosed  by 
means  of  a  cultivation  made  from  the  throat  on  the  surface  of  blood  serum. 
In  from  eighteen  to  twenty  hours,  when  the  growth  which  occurs  on  the 
surface  of  the  blood  serum  shows  colonies  of  the  Bacillus  diphtherias,  in  the 
case  of  diphtheria,  it  may  show  only  colonies  of  cocci  if  the  case  is  one 
of  simple  tonsillitis.  There  are  cases  of  real  diphtheria,  however,  in  which 
one,  two,  or  even  three  cultivations  from  the  throat  show  no  definite 
diphtheritic  bacilli ;  but  these  have  to  be  classed  as  doubtful  cases  from  an 
examination  of  the  throat,  and  are  to  be  considered  clinically  as  diphtheria, 
and  treated  as  such.  Otherwise  the  diagnosis  of  acute  tonsillitis  gives  rise 
to  no  difficulty.  The  knee-jerks  are  not  exaggerated  or  absent,  as  in  many 
cases  of  acute  diphtheria,  although  the  general  bodily  depression  may  be 
great,  and  albumin  or  even  blood  may  be  present  in  the  urine. 

Treatment. — In  the  early  stage,  when  the  patient  is  seen  with  a 
very  furred  tongue,  with  headache  and  high  fever,  the  treatment  is  best 
commenced  by  the  administration  of  a  mercurial  purgative,  such  as  3  or  5 
grs.  of  calomel,  followed  after  several  hours  by  a  dose  of  saline.  This  may 
be  repeated  on  the  following  day,  if  necessary,  and  in  all  cases  it  is  essential 
to  keep  the  bowels  well  open.  Other  treatment  is  directed  to  the  relief  of 
the  general  symptoms;  thus,  in  some  cases  continuous  treatment  with 
small  doses'  of  mercury  and  chalk  is  highly  beneficial ;  in  others,  again, 
with  high  fever,  the  administration  of  small  doses  of  aconite  is  useful, 
namely,.  1  or  2  minims  of  the  tincture  every  three  hours,  and  then  every 
hour  for  twelve  hours.  Larger  doses  of  tincture  of  aconite  are  frequently 
given,  but  it  must  be  remembered  that  aconite  has  a  powerful  depressing 
action  on  the  heart.  Salicylate  of  sodium,  in  10-  to  15-gr.  doses,  given  every 
three  hours,  is  frequently  beneficial  in  relieving  the  general  symptoms  of 
the  disease,  and  it  has  been  stated  by  some  to  even  cut  short  its  course. 
It  may  be  combined  with  ammonium  chloride  in  5-gr.  doses.  Guaiacum, 
in  the  form  of  ammoniatecl  tincture,  1-  to  2-drm.  doses  every  three  hours,  is 
frequently  useful  in  acute  tonsillitis.  It  may  be  given  with  an  alkali,  such 
as  bicarbonate  of  sodium,  but  it  is  apt  to  produce  diarrhoea,  and  when  this 
occurs  its  administration  must  be  temporarily  stopped.  Tincture  of  per- 
chloride  of  iron  in  10-  to  20-minim  doses,  frequently  administered,  is  a  useful 


640  ALIMENTARY  SYSTEM. 

remedy.  Local  treatment  is  of  great  service  in  relieving  the  troublesome 
symptoms  of  acute  tonsillitis.  The  treatment  is  both  antiseptic  and  sedative. 
The  sedative  treatment  may  be  carried  out  by  the  application  of  hot  fomen- 
tations to  the  throat,  glycerin  of  belladonna  being  painted  on  to  the  skin. 
In  some  cases  it  is  sufficient  to  rub  the  skin  and  the  neck  with  liniment  of 
belladonna,  subsequently  tying  a  flannel  round  the  neck.  Sedative  applica- 
tions to  the  throat  itself  are  useful  in  allowing  the  patient  to  swallow,  and 
for  relieving  the  pain.  The  best  of  sedative  applications  is  a  solution  of 
hydrochlorate  of  cocaine,  5  to  10  grs.  to  the  ounce,  painted  on  to  the  tonsils 
just  before  food  is  administered.  Cocaine  lozenges  may  also  be  given  in 
moderation.  The  sucking  of  ice  is  also  a  useful  sedative.  Other  local 
applications  to  the  throat  are  useful  for  washing  away  the  secretion,  and 
acting  as  antiseptics.  If  the  patient  may  gargle,  he  can  use  either  a  solution 
of  chlorate  of  potash  (100  gr.,  dilute  hydrochloric  acid  100  minims,  syrup 
4  dr.,  water  10  oz.),  or  the  throat  may  be  sprayed  with  a  solution  of 
bicarbonate  of  sodium  and  borax  (10  gr.  to  the  ounce),  and  of  carbolic  acid 
(|  gr.  to  the  ounce),  or  with  a  dilute  mercurial  spray  (1  in  5000  of  corrosive 
sublimate). 

Frequently  in  the  early  stages  of  acute  tonsillitis,  it  is  highly  beneficial 
to  paint  the  throat  once  with  a  solution  of  nitrate  of  silver  (10  to  20  grs. 
to  the  ounce).  This  procedure,  in  cases  of  mild  infection  of  the  tonsil, 
undoubtedly  cuts  short  the  disease.  The  throat  may  also  be  painted  with 
glycerin  of  carbolic  acid  (1  in  20)  or  glycerin  of  corrosive  sublimate 
(1  in  2000).  If  an  abscess  forms,  it  sometimes  bursts  spontaneously,  but 
may  be  frequently  ruptured  with  the  finger-nail,  or  it  may  be  opened  by 
means  of  a  knife. 

FOLLICULAK  TONSILLITIS. 

Acute  follicular  tonsillitis  is,  like  acute  tonsillitis,  an  infection  which 
may  either  result  from  a  catarrh  of  the  follicles,  or  an  acute  inflammation 
of  them,  due  to  one  or  other  form  of  coccus.  It  usually  occurs  in  children, 
and  in  its  acute  form  presents  practically  the  same  symptoms  as  acute 
tonsillitis.  The  treatment  is  also  practically  the  same,  except  that  it  is 
sometimes  beneficial  to  treat  the  suppurating  follicles  individually  with 
solution  of  nitrate  of  silver. 

On  examination,  patches  are  seen  over  the  tonsil,  which  suggest,  in 
some  cases,  a  diphtheritic  infection,  but  the  diagnosis  is  made  by  the 
same  method  as  in  acute  tonsillitis;  the  treatment  is  also  practically 
the  same. 

CHRONIC  TONSILLITIS. 

This  is  a  chronic  enlargement  of  the  tonsils,  which  may  result  from 
many  causes. 

Etiology. — The  affection  may  arise  from  acute,  simple,  or  follicular 
tonsillitis,  or  may  be  chronic  from  the  first.  In  the  first  case,  repeated 
attacks  of  acute  or  subacute  tonsillitis  lead  to  the  enlargement,  which  is 
due  to  fibroid  thickening  of  the  tonsillar  tissue,  with  some  increase  of  the 
lymphoid  cells.  In  chronic  inflammation  there  is  frequently  a  progressive 
enlargement  of  the  tonsils,  sometimes  more  marked  on  the  one  side  than 
the  other,  so  that  they  may  even  meet  in  the  middle  line.  The  surface  of 
the  tonsils  may  be  smooth,  but  is  more  usually  pitted,  and  the  tonsillar 


DISEASES  OF  THE  FAUCES  AND  TONSILS.  641 

crypts  may  be  completely  destroyed,  being  shown  only  by  shallow  markings 
on  the  surface  of  the  tonsil.  The  degree  of  change  varies :  thus  there  are 
hard  tonsils  and  soft  boggy  tonsils.  They  may  be  pale,  or  slightly  congested 
on  the  surface,  this  surface  congestion  frequently  leading  to  small 
haemorrhages.  The  uvula,  at  the  same  time,  is  frequently  elongated,  and 
there  may  be  coincident  pharyngitis,  which  is  kept  in  a  subacute 
condition  by  the  enlarged  tonsils  being  in  front  of  the  pharynx,  and  thus 
blocking  in  the  secretion. 

Chronic  tonsillitis  is  a  very  frequent  disease  in  children  and  young 
adults,  and  the  symptoms  it  presents  are  very  characteristic.  The  child 
walks  frequently  with  the  mouth  open,  and  sleeps  in  the  same  condition ; 
the  voice  is  nasal,  and  there  is  frequently  some  difficulty  of  respiration ; 
cough  is  often  present,  and  in  some  cases — especially  in  adults — it  may  be 
excessive,  especially  in  young  women  with  a  neurotic  temperament.  The 
cough  is  short,  hacking,  or  barking  in  character,  and  is  sometimes 
accompanied  by  a  glairy  expectoration.  It  is  not  infrequently  severe  in 
the  early  morning,  and  bleeding  is  not  uncommon,  the  pillow  of  the  child 
being  stained  with  blood,  or  the  lips  and  gums  being  found  covered  with 
blood  in  the  morning.  Children  suffering  from  chronic  tonsillitis  frequently 
lose  their  appetite,  become  pale  and  flabby,  and  lose  flesh,  while  the  bowels 
are  usually  constipated. 

One  of  the  chief  features  in  children  is  the  tendency  to  bronchitis 
which  they  exhibit;  in  many  cases  the  bronchitis  is  kept  up  by  the 
enlargement  of  the  tonsils,  and  so  much  so  that  it  is  not  until  they  are 
removed  that  the  bronchitis  is  cured.  In  cases  of  prolonged  enlargement 
of  the  tonsils,  usually  with  repeated  attacks  of  bronchitis,  but  sometimes 
without,  deformity  of  the  chest  may  ensue,  either  with  a  flattening  or 
more  commonly  the  "  pigeon  breast."  Enlarged  tonsils  may  be  associated 
with  tuberculosis,  but  there  is  no  evidence  that  the  association  is  other 
than  accidental.  In  some  cases,  however,  there  are  enlarged  glands  at 
the  angle  of  the  jaw,  associated  with  enlarged  tonsils,  and  these  glands 
are  eventually  found  to  be  tuberculous,  there  being  usually  no  tuberculous 
lesion  to  the  tonsil  itself.  This  only  means  that  the  tuberculous  infection 
has  taken  place  through  the  tonsil  or  pharynx,  and  infected  the  glands  of 
the  neck. 

Course,  prognosis,  and  treatment.  —  The  course  of  chronic 
tonsillitis  in  children  is  a  very  variable  one.  It  is  usually  associated  with 
some  anaemia,  wasting,  and  disordered  digestion ;  and,  as  has  been  stated, 
more  especially  in  the  winter,  it  is  associated  with  recurrent  attacks  'of 
bronchitis.  In  many  cases,  simply  by  a  general  tonic  treatment,  cod-liver 
oil,  iron,  and  maltine,  as  well  as  by  treatment  directed  to  the  relief  of  the 
bronchitis,  such  patients  do  well,  and  the  tonsils  diminish  in  size,  although 
this  may  take  some  months  to  accomplish.  The  local  treatment  which  is 
to  be  employed  is  the  use  of  astringents,  in  the  form  either  of  tincture  of 
iron  and  glycerin  (1  drm.  of  the  tinctura  ferri  perchloridi  to  1  oz.  of 
glycerin),  or  tannin  and  glycerin  (10  grs.  to  the  ounce).  If  there  is  much 
irritation  of  the  throat,  glycerin  with  borax  may  be  used  instead  of  astrin- 
gent lotions,  or  a  solution  of  iodine  and  iodide  of  potash,  or  of  menthol  and 
olive  oil  (10  to  20  grs.  to  the  ounce)  may  be  used,  or  the  menthol  may  be 
applied  in  a  spray  form,  after  dissolving  in  parolein. 

The  question  of  the  removal  of  the  tonsils  frequently  arises,  and  with 
regard  to  this  it  may  be  said  that,  apart  from  the  existence  of  adenoids,  the 
tonsils  may  themselves  give  rise  to  obstruction  to  the  respiration,  as  for 

VOL.  I. — 41 


642  ALIMENTARY  SYSTEM. 

example  when  they  nearly  meet  in  the  middle  line.  In  these  cases  their 
removal  is  essential  for  the  improvement  of  the  patient,  as  well  as  for  the 
relief  of  the  bronchitis.  In  not  a  few  cases,  however,  recovery  takes  place 
without  the  removal  of  the  tonsils,  and  even  when  the  tonsils  have  been 
removed  they  frequently  become  large  again.  The  indications  for  the 
removal  are  when  they  interfere  with  the  respiration,  and  when  there  is 
much  pharyngeal  and  post-nasal  inflammation,  with  some  degree  of  deaf- 
ness. The  effects  of  removal,  however,  are,  as  has  been  indicated,  frequently 
disappointing.  The  tonsils  may  remain  large  many  years,  up  to  the  age  of 
puberty,  when  they  tend  to  diminish ;  but  in  some  cases  their  enlargement 
persists  in  young  adult  life. 

SIDXEY  MAKTIK 


DISEASES   OF  THE  PHARYNX. 

PHARYNGITIS. 

Pharyngitis  is  a  condition  of  inflammation  of  the  pharynx,  and  may  be 
associated  with  some  acute  diseases  of  the  tonsils  and  fauces,  as  in  diphtheria, 
scarlet  fever,  and  measles,  and  it  may  also  exist  by  itself  in  a  catarrhal 
form,  acute  or  chronic,  and  may  in  one  form  be  chiefly  shown  by  an 
enlargement  of  the  lymphoid  tissue,  as  in  granular  pharyngitis. 

In  acute  pharyngitis  the  mucous  membrane  is  dusky  red  in  colour,  is 
swollen,  and  is  covered  on  the  surface  with  a  layer,  frequently  very  tenacious, 
of  mucus -containing  pus  cells,  but  not,  as  a  rule,  blood.  There  are  well- 
marked  signs  of  irritation  of  the  throat,  not  so  much  in  the  form  of  cough 
as  in  a  feeling  of  stiffness,  of  pain  in  deglutition,  and  of  a  tendency  to 
repeated  acts  of  swallowing,  which  increase  the  distress.  There  is  hawking 
of  phlegm,  which  is  difficult  to  remove,  and  in  consequence  vomiting  is  not 
infrequent.  A  slight  degree  of  fever  is  sometimes  associated  with  the  con- 
dition, but  it  does  not  last  long. 

The  treatment  in  the  initial  stage  is  by  the  administration  of  a 
mercurial  purgative  and  the  application  of  sedative  sprays  or  lotions. 
Gargling  is  not  of  much  value,  inasmuch  as  it  does  not  completely  reach 
the  pharynx ;  but  the  application  of  hot  sprays,  or  a  cold  spray  containing 
bicarbonate  of  sodium  (10  grs.  to  the  ounce)  is  very  beneficial.  Sedative 
lozenges,  such  as  cocaine,  are  of  use. 

Acute  simple  pharyngitis  may  lead  to  oedema  or  ulceration,  or  pass  into 
the  chronic  form ;  it  may  simply  be  an  exacerbation  of  the  chronic  condition. 

In  chronic  pharyngitis  the  catarrh  leads  to  several  different  conditions. 
There  is  a  continuous  secretion  of  mucus  in  some  cases,  in  others  a  greatly 
diminished  secretion.  In  the  first  case  the  epithelium  is  more  or  less 
intact,  and  is  proliferating,  and  in  the  second  case  the  epithelium  is  partly 
detached,  and  is  deficient  in  vitality. 

Chronic  inflammation  leads  to  fibrosis  of  the  mucous  membrane,  to  a 
dilatation  of  the  small  venules  in  the  pharynx,  and  generally  to  a  condition 
of  atrophy.  In  chronic  pharyngitis  several  varieties  may  be  distinguished, 
such  as  pharyngitis  sicca,  or  dry  pharyngitis ;  pharyngitis  atrophica ;  and 
granular  pharyngitis.  In  the  last  case  the  stress  of  the  inflammation  is 
on  the  follicles,  which  enlarge,  forming  raised  patches,  frequently  coalesce, 


DISEASES  OF  THE  (ESOPHAGUS.  643 

forming  projecting  masses,  glazed  on  the  surface.  There  may  be  dilated 
vessels,  which  sometimes  give  way,  causing  haemorrhage.  The  amount  of 
blood  lost  is,  however,  never  large,  being  limited  to  streaks  or  spots  in  the 
mucus  expectorated. 

Chronic  pharyngitis  in  a  moderate  degree  may  not  give  rise  to  many 
symptoms,  except  that  occasionally  there  are  exacerbations  leading  to  the 
symptoms  of  subacute  pharyngitis.  In  other  cases  it  leads  to  great  distress 
in  speaking,  singing,  and,  to  some  degree,  in  swallowing.  An  accumulation 
of  mucus  on  the  surface,  especially  in  the  upper  part  of  the  pharynx,  leads 
to  hawking,  and  even  vomiting,  in  the  morning.  Chronic  pharyngitis  fre- 
quently spreads  downwards  to  the  epiglottis,  to  the  ventricular  bands,  and 
to  the  vocal  cords,  leading  to  hoarseness  and  aphonia. 

The  treatment  is  directed  to  improve  the  chronic  catarrhal  condition 
by  attending  to  the  general  health,  and  by  the  application  of  astringents, 
either  in  the  form  of  spray,  or  of  paint,  and  of  sedatives,  such  as  menthol 
and  cocaine  if  there  is  much  distress.  Caustics  may  be  applied  to  the 
follicles  when  they  form  large  masses.  It  is  sometimes,  however,  an 
obstinate  condition,  and  frequently  treatment  is  of  but  little  avail,  the 
patient  only  recovering  on  removal  to  a  dry  climate. 

SIDNEY  MARTIN. 


DISEASES   OF  THE   (ESOPHAGUS. 

The  oesophagus  is  about  9  \  in.  long,  and  extends  from  the  pharynx 
to  the  stomach.  The  commencement  is  6  in.  from  the  incisor  teeth, 
and  opposite  the  sixth  cervical  vertebra:  the  termination  is  15J  in. 
from  the  incisor  teeth  and  opposite  the  tenth  dorsal  vertebra,  correspond- 
ing in  front  to  the  level  of  the  ensiform  process.  "When  quiescent,  its  walls 
are  opposed  to  each  other,  the  mucous  membrane  lying  in  longitudinal 
rugae.  It  lies  at  first  behind,  and  then  to  the  left  side  of  the  trachea, 
passing  down  in  front  of  the  vertebral  column.  It  is  supplied  with  nerves 
from  the  vagus  and  sympathetic.  In  structure  it  is  possessed  of  three  chief 
coats.  There  is  a  thin  external  connective  tissue  coat ;  next  to  this  is  the 
muscular  coat,  composed  of  an  inner  thick  circular  layer  with  an  outer 
thin  longitudinal  layer.  The  upper  third  of  the  oesophagus  contains 
striped  muscular  fibres  ;  in  the  lower  two-thirds  these  are  unstriped.  The 
submucous  coat  consists  of  connective  tissue,  which  contains  blood  vessels, 
lymphatics,  and  glands.  These  latter  open  out  in  the  mucous  membrane, 
which  is  composed  of  epithelium,  and  separated  from  the  submucous  by 
a  thin  muscular  coat,  the  muscularis  mucosae.  The  act  of  deglutition, 
which  is  voluntary  as  far  as  the  pharynx,  is  involuntary  when  the 
pharyngeal  muscles  contract  over  the  swallowed  mass.  The  contraction  of 
the  pharynx  passes  this  on  to  the  oesophagus,  which  by  its  peristaltic 
action  continues  it  on  to  the  stomach.  This  peristaltic  movement  is  not 
stopped  even  when  the  oesophagus  is  ligatured,  or  when  a  portion  of  it  is 
removed.  The  motor  nerve  of  the  oesophagus  is  the  vagus,  and  if  this  be 
divided  the  food  collects  in  the  lower  part  of  the  gullet.  The  afferent 
nerve  fibres  of  deglutition  are  the  palatine  branches  of  the  fifth  cranial 
nerve,  and  the  pharyngeal  branches  of  the  vagus.  In  disease  the  oesophagus 
is  also  capable  of  a  reverse  peristalsis. 


644  ALIMENTAR  Y  S  YSTEM. 

The  oesophagus  may  be  examined  by  the  passage  of  a  bougie,  or  by  means 
of  the  sounds  heard  in  the  stomach  and  produced  by  a  swallowed  bolus.  When 
solid  food  is  swallowed,  two  sounds  are  heard  by  the  stethoscope  placed  over 
the  stomach.  The  first  is  produced  by  the  bolus  entering  the  stomach,  and 
the  second  at  the  end  of  swallowing,  when  the  remaining  part  of  the  bolus  is 
squeezed  through  the  cardia.  Normal  deglutition  lasts  about  six  seconds. 
No  sound  is  heard  over  the  healthy  stomach  when  water  alone  is  swallowed, 
unless  it  be  mixed  with  air.  The  examination  of  liquids  regurgitated  from 
the  oesophagus  sometimes  yields  important  results,  inasmuch  as  the  food 
never  having  entered  the  stomach,  it  has  not  been  exposed  to  the  action  of  the 
gastric  juice.  The  regurgitated  mass  does  not,  therefore,  contain  peptones 
(unless  these  have  been  administered  in  the  food),  and  is  alkaline.  If  the 
regurgitated  liquids  contain  free  hydrochloric  acid,  as  shown  by  the  tests 
described  under  "Diseases  of  the  Stomach,"  p.  651,  the  liquid  must  have 
come  from  the  stomach.  Passage  of  the  sound  is  a  usual  method  in  the 
examination  of  the  diseases  of  the  oesophagus,  especially  when  a  stricture 
is  suspected.  The  same  precautions  which  are  taken  for  the  passing  of  the 
sound  in  diseases  of  the  stomach,  must  be  observed  when  it  is  used  for  the 
oesophagus ;  especially  must  the  evidences  of  thoracic  aneurysm  be  sought 
for  before  the  instrument  is  used.  The  sound  may  pass  easily  into  the 
stomach,  as  in  cases  where  there  is  no  stricture.  It  may  be  held  by  the 
stricture,  and  with  gentle  pressure  the  resistance  may  be  overcome,  as  in 
cases  of  spasmodic  stricture ;  or  it  may  be  prevented  from  entering  the 
stomach  by  an  organic  stricture.  In  the  latter  case,  on  removal,  the  sound 
may  be  covered  with  mucus  or  blood;  but  not  infrequently  in  cancer, 
most  of  the  bleeding  occurs  afterwards. 

The  oesophagus  being  a  portion  of  the  alimentary  tract  in  which  food 
remains  but  a  very  short  time,  it  is  rarely  the  seat  of  infective  disease. 
Tuberculous  ulceration  is  of  extreme  rarity.  Syphilitic  ulceration,  pro- 
ducing stricture,  has  been  observed.  The  diphtheritic  membrane  may,  in 
rare  cases,  extend  from  the  pharynx  down  the  oesophagus,  but  as  a  rule 
infective  diseases  do  not  spread  from  the  pharynx  to  the  oesophagus.  The 
gullet  may  be  the  seat  of  aphtha?,  spreading  from  the  mouth. 

The  diseases  which  will  be  discussed  are — (1)  the  results  of  injury,  due 
to  the  presence  of  foreign  bodies,  or  to  the  swallowing  of  corrosive  sub- 
stances and  hot  liquids ;  (2)  diverticula ;  (3)  dilatation  without  stricture ; 
(4)  stricture,  spasmodic  and  organic  (simple  or  malignant). 


INFLAMMATION. 

Oesophagitis,  or  inflammation  of  the  gullet,  is  the  result  of  injury, 
of  infection  following  a  new  growth,  or  of  the  extension  of  surrounding 
inflammation. 

Perforation  of  the  gullet  occurs  from  foreign  bodies,  from  new  growths, 
or  by  the  opening  of  a  tuberculous  abscess  (usually  globular),  or  an  aneurysm 
into  the  gullet. 

Impaction  of  foreign  bodies  in  the  oesophagus  leads  to  ulceration  of  the 
wall,  with  frequently  an  infection  of  the  coats,  and  a  diffuse  cellulitis 
outside,  with  or  without  perforation.  Pleurisy  may  also  follow  impaction 
of  a  foreign  body,  ending  in  effusion  or  empyema.  The  treatment  and 
other  results  of  foreign  bodies  need  not  be  here  discussed. 

The   swallowing    of    corrosive   substances   (mineral   acids    or    caustic 


DISEASES  OF  THE  (ESOPHAGUS  645 

alkalies)  leads  to  inflammation  and  ulceration,  and  subsequently  stricture 
of  the  oesophagus. 

The  initial  symptoms  to  which  swallowing  of  these  substances  gives 
rise,  is  a  sense  of  burning  pain  along  the  oesophagus,  in  the  neck,  behind 
the  sternum,  and  in  the  back.  The  chief  pain  is  not  infrequently  ascribed 
to  the  region  of  the  manubrium.  When  the  severe  symptoms  have  passed 
off,  the  patient  may  experience  no  further  trouble,  and  it  will  not  be  till 
some  time  afterwards  that  difficulty  of  swallowing  is  experienced.  It  is 
first  shown  in  the  difficulty  of  getting  solid  food  into  the  stomach,  the 
patient  stating  that  it  sticks  at  one  part.  Eegurgitation  of  food  then 
follows  to  a  greater  or  less  extent ;  and  an  examination  by  means  of  the 
bougie  shows  that  there  is  stricture  at  one  or  other  part  of  the  gullet. 
The  treatment  in  such  cases  is  by  means  of  gradual  dilatation  of  the 
stricture  by  the  use  of  bougies ;  in  this  way  the  stricture  may  be 
sufficiently  dilated  to  allow  the  proper  amount  of  food  to  be  swallowed. 
In  some  cases,  however,  the  stricture  is  practically  impermeable,  and 
gastrostomy  has  to  be  performed.  Such  patients  are  liable  to  die  of 
starvation. 

DIVEETICULA. 

A  pressure  pouch  of  the  oesophagus  is  a  rare  condition.  It  consists  in 
a  pouch,  of  greater  or  less  size,  being  formed  at  the  junction  of  the 
pharynx  and  oesophagus.  Such  pouches  have  been  described  as  possibly 
due  to  defective  development,  as  in  the  case  of  Meckel's  diverticulum  of 
the  small  intestine.  In  other  cases  they  have  been  ascribed  to  a  lesion  of 
the  mucous  membrane,  produced  by  a  foreign  body,  and  subsequent  forma- 
tion of  a  pouch  by  pressure  from  within.  The  pouch,  which  is  formed  in 
the  position  above  described,  projects  at  the  back  of  the  gullet,  and  bulges 
on  both  sides  of  the  neck ;  in  some  cases,  however,  only  on  the  left  side. 
The  recognition  of  this  as  a  pressure  pouch  is  by  observing  that  it  is  larger 
after  a  meal ;  that  gas  and  particles  of  food  can  be  pressed  out  of  it ;  and 
that  food  returns  for  some  time — perhaps  hours — after  a  meal,  in  an 
undigested  condition,  the  return  of  food  being  associated  with  coughing  or 
some  such  act.  Owing  to  the  pressure  of  the  distended  pouch  on  the 
oesophagus,  there  is  difficulty  of  swallowing,  and  the  passage  of  a  sound 
shows  that  there  is  no  organic  obstruction  to  the  gullet.  In  the  cases 
which  have  been  recorded,  the  pouch  has  lasted  for  many  years,  arid 
death  has  been  due  to  some  other  cause.  In  others,  however,  death  has 
been  partly  due  to  starvation  from  pressure  on  the  gullet.  Pressure 
pouches  are  such  rare  conditions,  that  their  treatment  is  a  matter  of 
discussion;  but  the  proper  treatment  seems  to  be  that  performed  by 
v.  Bergmann,  and  done  once  in  this  country  by  Butlin ;  it  is  the  perform- 
ance of  an  operation  for  the  removal  of  the  pouch.  Both  in  v.  Bergmann's 
and  Butlin's  cases,  complete  recovery  followed  the  operation.  Gastrostomy 
has  been  performed  when  the  pressure  on  the  oesophagus  has  been  very 
great.  This  cannot  be  considered  a  treatment  at  all  comparable  to  the 
removal  of  the  pouch,  as  this  cures  the  condition. 


646  ALIMENT AR  Y  S  YSTEM. 


DILATATION. 

This  is  also  a  very  rare  condition  of  the  oesophagus,  but  it  does  occur, 
and  may  cause  death.  Thus,  in  one  case,  a  patient,  a  female,  set.  35,  was 
admitted  into  the  hospital  for  difficulty  in  breathing.  The  history  of  the 
case  showed  that  it  was  one  in  which  the  chief  symptoms  were  attacks  of 
vomiting,  and  pain  in  the  upper  part  of  the  abdomen.  These  attacks  came 
on  at  intervals.  While  she  was  in  the  hospital,  dyspnoea  and  regurgitation 
of  food  were  the  chief  symptoms  observed.  Dyspnoea  was  shown  by 
marked  stridor,  especially  after  exertion,  and  there  was  frequent  cough, 
brassy  in  character,  with  slight  expectoration.  The  breath  sounds  were 
somewhat  stridulous  over  the  left  apex.  The  presence  of  a  mediastinal 
tumour  was  suspected,  though  there  was  no  other  evidence  of  it.  There 
were  no  physical  signs  in  the  abdomen.  The  patient  died  from  exhaustion 
and  dyspnoea.  The  post-mortem  examination  revealed  somewhat  recent 
pleurisy  of  the  right  side,  and  some  recent  broncho-pneumonia  in  the  right 
lower  lobe.  The  only  condition  accounting  for  death  was  a  greatly  dis- 
tended oesophagus ;  the  enlargement  extending  the  whole  length  of  the 
tube,  the  greatest  transverse  diameter  being  5 J  in.  The  swelling  was 
pyriform,  and  bulged  into  the  right  pleura  and  into  the  pericardium,  but  it 
did  not  produce  any  evident  compression  of  the  trachea.  It  contained  a 
large  quantity  of  undigested  food.  There  was  no  stricture  of  the  cardia, 
and  no  new  growth.  The  walls  of  the  gullet  were  thin,  except  the 
mucous  membrane ;  the  epithelium  was  irregularly  thickened  throughout, 
and  showed  in  many  places  superficial  erosions,  evidently  the  result  of  the 
pressure  of  the  contained  food.  Microscopical  examination  of  the  gullet 
showed  that  there  was  fatty  degeneration  of  the  striated  muscle  fibres  of 
the  upper  third,  and  in  the  lower  two-thirds  the  unstriated  muscle  showed 
signs  of  atrophy.  There  was  no  sign  of  fibrosis  of  the  wall,  nor  of  any 
chronic  inflammation.  Other  cases  have  been  published  showing  the 
same  symptoms.  The  origin  of  the  disease  is  obscure.  The  only  explana- 
tions which  appear  probable,  are,  that  it  is  a  primary  nerve  defect,  since 
accumulation  of  food  in  the  oesophagus,  with  subsequent  dilatation  of  it, 
is  produced  by  secretion  of  both  vagus  nerves,  or  that  it  is  due  to  persistent 
spasm  of  the  cardia. 

STEICTUEE. 

Stricture  of  the  oesophagus  is  either  spasmodic  or  organic.  In  the 
latter  case  it  is  either  simple  stricture,  due  to  cicatricial  contraction,  or 
malignant,  due  to  epithelioma.  What  may  be  called  false  stricture  of 
the  oesophagus  is  produced  by  pressure  upon  it,  either  by  thoracic 
aneurysm,  by  a  new  growth  in  the  mediastinum,  or  by  a  very  large 
pericardial  effusion. 

Spasmodic  Stihctuke 

is  due  to  spasm  of  the  muscular  coat ;  it  is  sudden  in  onset,  and  occurs 
in  a  paroxysmal  manner.  The  patients  who  complain  of  it  are  usually 
hysterical  females  or  hypochondriacal  men.  There  may  be  pain,  and 
regurgitation  of  food  is  common.  It  is  not  usually  associated  with  wasting, 
although  cases  have  been  described  where  great  wasting  has  occurred,  and 
even  death  has  followed  starvation.     The  passage  of  a  bougie  clears  up  the 


DISEASES  OF  THE  (ESOPHAGUS.  647 

case,  as  by  gentle  pressure  the  spasm  is  overcome,  and  the  stomach  is 
entered  by  the  bougie.  The  passage  of  the  bougie  under  chloroform- 
narcosis  may  be  advisable  in  some  cases.  The  treatment  is  that  employed 
for  nervous  conditions  generally,  namely,  the  moral  persuasion  of  the 
patient,  the  administration  of  tonics,  and  the  regulation  of  the  mode  of  life. 

Malignant  Stkictuee. 

The  stricture  of  the  oesophagus,  clue  to  cicatricial  contraction,  has 
already  been  considered,  and  it  now  remains  to  discuss  stricture  due  to 
the  development  of  a  new  growth  in  the  walls  of  the  gullet.  The  kind 
of  new  growth  is  almost  invariably  squamous  epithelioma.  It  occurs 
most  frequently  in  the  lower  third  of  the  oesophagus,  producing  a  stricture 
near  the  cardiac  orifice  of  the  stomach.  Next,  most  frequently  it  occurs 
in  the  upper  third,  and  is  least  common  in  the  middle  of  the  oesophagus. 
In  its  growth  it  slowly  contracts  the  lumen  of  the  gullet,  and  above 
the  constriction  the  walls  dilate  and  hypertrophy.  The  amount  of 
dilatation  and  hypertrophy  present  depends  upon  the  slowness  of  the 
development  of  the  growth  and  the  amount  of  stricture  produced.  With 
some  forms  there  is  rapid  ulceration,  and  but  little  hypertrophy  is  pro- 
duced. The  extent  of  the  growth,  which  arises  in  the  mucous  membrane, 
varies  at  death.  It  may  extend  over  two  or  three  inches,  and  tends 
to  infiltrate  the  walls  and  to  spread  upwards  and  downwards  along  the 
mucous  membrane.  It  does  not  commonly,  however,  extend  from  the 
cardia  far  into  the  stomach,  nor  in  the  upper  third  does  it  extend  into  the 
pharynx.  Perforation  may  occur  into  the  cellular  tissue  of  the  neck  or 
posterior  mediastinum,  or  into  the  trachea  or  pleura,  usually  of  the  left 
side,  and  is  as  a  rule  produced  by  septic  ulceration  of  the  walls  of  the 
gullet  above  the  cancer.  When  it  has  occurred,  it  leads,  in  the  cellular 
tissue,  to  a  diffuse  cellulitis,  ending  either  in  suppuration  or  in  gangrene. 
The  cellulitis  may  spread  down  the  neck  into  the  thorax,  and  may  produce 
acute  pericarditis  or  gangrene  of  the  upper  part  of  the  lung.  It  may  also, 
as  in  one  case  observed,  produce  a  thickening  of  the  sides  of  the  larynx, 
involving  the  recurrent  laryngeal  nerve,  thus  causing  paralysis  of  one  vocal 
cord.  Perforation  into  the  trachea  is  not  so  common,  but  may  lead  to 
septic  broncho-pneumonia.  Perforation  into  the  pleura  causes  empyema, 
often  putrid  in  character.  Perforation  may  also  occur  into  the  aorta,  pro- 
ducing death  from  haemorrhage ;  or  into  the  pericardium,  producing  acute 
pericarditis.  Secondary  growths  may  occur  in  the  glands  near  the  gullet, 
more  rarely  in  the  organs  of  the  body,  sometimes  the  liver.  In  cancer  of 
the  oesophagus,  death  occurs  partly  from  starvation  and  partly  from  the 
complications  of  perforation,  which  have  just  been  described. 

Symptoms. — Cancer  of  the  oesophagus  occurs  in  middle  age  (40  to  50 
years),  usually  in  men,  and  the  symptoms  are,  as  a  rule,  definite.  They  are 
very  insidious  in  origin ;  the  first  symptoms  the  patient  complains  of  being, 
as  a  rule,  a  gradually  increasing  difficulty  in  swallowing  solid  food,  liquids 
being  swallowed  at  first  with  ease.  This  difficulty  varies  from  time  to  time, 
but  gradually  increases  until  no  solid  food  is  taken.  The  patient  frequently 
comes  for  advice  at  this  period,  and  it  is  found,  on  testing  his  powers  of 
swallowing,  that  the  swallowed  food  regurgitates  after  a  time  in  an 
undigested  and  still  alkaline  condition,  showing  that  it  has  not  entered  the 
stomach.  Associated  with  the  difficulty  of  swallowing  is  great  wasting, 
and  the  symptoms,  which  have  perhaps  lasted  two  or  three  months,  may 


648  ALIMENTARY  SYSTEM. 

have  been  attended  by  a  loss  of  two  or  three  stones  in  weight ;  otherwise, 
there  may  be  no  cancerous  cachexia.  Indeed,  some  of  these  patients 
at  this  time  preserve  their  fresh  complexion.  Later  on  it  gives  place  to 
the  sallowness  of  cancerous  disease.  An  examination  by  the  oesophageal 
bougie  must  now  be  made,  and  it  is  found  that  this  does  not  pass  into 
the  stomach,  but  is  held  some  distance  down  the  oesophagus.  On 
withdrawing  the  bougie,  it  may  in  some  cases  be  found  to  be  covered 
with  particles,  which  on  examination  show  cancerous  cells,  or  it  may  be 
covered  with  blood,  and  its  use  is  frequently  followed  by  slight  bleeding ; 
or  it  may  in  some  cases  be  covered  with  mucus,  and  its  use  be  followed  by 
the  discharge  of  a  large  quantity  of  thick  unpigmented  mucus.  From 
this  combination  of  symptoms  the  diagnosis  of  stricture  of  the  oesophagus 
can  be  made.  The  sensations  which  the  patient  complains  of  at  this  time, 
apart  from  those  of  swallowing,  vary  to  some  extent.  Pain  is  present, 
referred  to  the  chest,  to  the  back,  or  to  a  particular  point  behind  the 
sternum.  But  pain  is  not  a  marked  feature  in  cases  of  cancer  of  the 
gullet.  The  sensations  following  swallowing  are  frequently  located  to  the 
region  of  the  manubrium  of  the  sternum,  or  to  the  end  of  the  sternum, 
that  is,  the  upper  part  of  the  epigastrium.  A  tumour  can  rarely  be  felt, 
even  when  the  disease  is  situated  in  the  neck.  If  a  patient  be  seen  in  the 
later  stages,  emaciation  may  be  extreme,  but  the  chief  points  which  give 
rise  to  the  difficulty  in  the  recognition  of  the  disease  lie  in  the  presence  of 
complications.  Thus  the  patient  may  present  himself  for  the  first  time 
with  the  symptoms  and  signs  of  pleuritic  effusion  or  empyema,  and  unless 
a  careful  history  be  taken  in  such  cases,  the  primary  disease  is  apt  to  be 
missed.  In  cases  of  diffuse  cellulitis  of  the  neck,  also,  the  local  disease 
may  be  unrecognised,  especially  when  the  upper  part  of  the  lung  is  affected. 
In  some  such  cases  paralysis  of  the  vocal  cord  may  occur,  and  the  diagnosis 
from  thoracic  aneurysm  or  mediastinal  tumour  may  be  extremely  difficult, 
if  not  impossible,  until  a  post-mortem  examination  is  made.  Similarly, 
too,  if  the  malignant  ulcer  produces  a  septic  bronchitis  by  ulceration  of  the 
trachea,  the  signs  and  symptoms  of  this  may  obscure  the  primary  disease, 
as  well  as  in  the  case  in  which  a  subphrenic  abscess  is  the  result  of 
perforation  of  the  cancerous  ulcer.  The  only  way  in  which  these 
conditions  can  be  diagnosed  as  secondary  to  cancer  of  the  oesophagus,  is  by 
careful  attention  to  the  history  of  the  case  and  by  an  examination  of  the 
oesophagus  by  means  of  a  sound. 

Diagnosis  and  prognosis. — The  diagnosis  of  cancer  is  made  from 
the  following  points :  its  occurrence  is  usually  in  a  man  of  middle  age,  the 
symptoms  of  stricture,  that  is,  of  the  difficulty  of  entrance  of  food  into  the 
stomach  and  of  its  regurgitation ;  and  the  recognition  of  this  stricture  by 
the  use  of  the  oesophageal  bougie.  Diagnosis  is  aided,  in  some  instances, 
by  auscultation  of  the  swallowing  sounds ;  the  second  sound  is  described 
as  being  absent  in  stricture  of  the  oesophagus.  The  disease  is  associated 
with  great  emaciation,  which  is  due  more  to  the  starvation  induced  than 
to  the  cancerous  disease  itself. 

Cancer  of  the  oesophagus  is  always  fatal,  and  the  duration  is  somewhat 
less  than  that  of  cancer  of  the  stomach,  inasmuch  as  the  starvation  is 
greater,  and  complications,  such  as  perforation  and  fatal  haemorrhage,  more 
frequently  occur. 

Treatment. — The  object  of  treatment  is  palliative,  namely,  the 
relief  of  pain  by  the  administration  of  sedatives,  such  as  morphine,  and  the 
adoption  of  means  for  getting  more  food  into  the  stomach,  as  by  this  means 


DISEASES  OF  THE  STOMACH.  649 

the  patient's  condition  is  greatly  improved.  It  is  possible,  in  many  cases, 
to  pass  a  small  tube  through  the  stricture,  and  this  may  be  kept  in  position 
and  the  patient  fed  continually  through  it.  In  other  cases  it  need  not  be 
kept  in  position,  but  only  passed  when  food  is  required.  Gastric  digestion 
is,  as  a  rule,  good,  and  therefore  the  patient  can  take  a  large  amount  of 
food.  Gastrostomy  has  been  performed  in  order  to  feed  the  patient  more 
effectually..  It  cannot,  however,  be  said  to  have  any  advantages  over 
feeding  by  the  tube,  if  this  is  possible.  Feeding  by  the  tube  has  one 
danger,  namely,  that  of  perforation  of  the  soft  walls  of  the  gullet  above  the 
cancerous  infiltration,  and  this  has  occurred  not  infrequently,  so  that  the 
catheter  has  passed  into  the  pleural  cavity,  causing  death  by  septic  in- 
flammation. Where  feeding  by  the  tube  is  impossible,  gastrostomy  is  not 
considered  advisable,  and  feeding  by  the  rectum  is  to  be  adopted  in  the 
manner  described  in  the  article,  "  Diseases  of  the  Stomach."  The  course, 
however,  in  spite  of  all  treatment,  is  usually  a  progressively  downward 
one 

SIDNEY  MAETIN. 


DISEASES  OF  THE  STOMACH. 

A  DISCUSSION  of  the  diseases  of  the  stomach  is  necessarily  preceded  by 
a  short  account  of  the  anatomy  and  physiology  of  the  organ ;  for  without 
the  former  a  correct  appreciation  cannot  be  formed  of  the  changes  which 
can  be  discovered  by  physical  signs  in  organic  diseases  of  the  stomach ; 
and  without  the  latter  no  clear  ideas  can  be  formed  of  the  changes  in 
functional  disease  of  the  organ. 


INTEODUCTOEY. 

The  stomach  is  a  pear-shaped  bag,  almost  completely  surrounded  by 
peritoneum,  lying  in  the  upper  part  of  the  abdominal  cavity,  and  extending 
from  below  the  left  vault  of  the  diaphragm  to  the  right  side  of  the  vertebral 
column.  It  is  divided  artificially  into  a  cardiac  and  pyloric  region,  an 
anterior  and  posterior  surface,  and  a  lesser  and  greater  curvature.  In  size 
it  varies  according  to  age  and  sex,  and  in  each  individual  at  different  times, 
according  to  the  degree  of  distension.  When  fully  distended  it  is  about 
9 \  to  10^  in.  in  its  longest  diameter,  and  3  to  3|  in.  from  before  back; 
while  the  average  capacity  of  the  adult  stomach  is  a  little  over  a  litre,  or 
from  35  to  40  oz. ;  the  variations,  however,  which  have  been  found  by 
Ewald,  are  from  9  to  59  oz.  A  capacity  of  more  than  3  jmits  must  be 
considered  as  pathological. 

In  its  natural  position  the  stomach  lies  almost  vertically,  the  cardiac 
orifice  being  situated  15^  in.  from  the  incisor  teeth,  and  on  the  left  side 
of  the  body  of  the  tenth  dorsal  vertebra,  and  in  a  line  with  a  point  1  in. 
from  the  sternal  insertion  of  the  seventh  left  costal  cartilage.  The  lesser 
curvature  extends  from  the  cardia  vertically,  along  the  left  side  of  the 
bodies  of  the  tenth,  eleventh,  and  twelfth  dorsal  vertebras  to  the  pylorus, 
which  is  situated  on  the  right  side  of  the  first  lumbar  vertebra ;  this  is 
opposite   a  point  in  the   epigastrium   below  the   xiphisternum   and  just 


650  ALIMENTAR  V  S  YSTEM. 

outside  the  parasternal  line.  The  stomach  is  held  in  position  by  the 
cesophagus  and  by  the  duodenum,  as  well  as  by  the  folds  of  the  omentum 
attached  to  it.  The  lower  limit  of  the  greater  curvature  of  the  distended 
stomach  in  the  normal  individual  is  marked  by  a  transverse  line  between 
the  cartilages  of  the  ninth  ribs  or  sometimes  the  tenth.  This  is  two 
fingers'  breadth  above  the  umbilicus.  The  anterior  surface  of  the  stomach 
touches  the  liver,  the  diaphragm,  and,  below,  the  anterior  abdominal  wall. 
The  posterior  surface  of  the  stomach  touches  from  above  down  the  dia- 
phragm, spleen,  kidney,  pancreas,  and  mesocolon. 

The  four  coats  of  the  stomach  are  peritoneal,  muscular,  submucous, 
and  mucous.  The  three  layers  of  the  muscular  coat  are  the  external 
longitudinal,  the  circular,  and  the  slightly  developed  oblique  coat.  The 
mucous  coat  is  separated  from  the  submucous  by  the  muscularis  mucosas. 
It  is  composed  of  two  classes  of  glands,  cardiac  and  pyloric.  The  former 
contain  two  kinds  of  cells — small  central  cells  secreting  pepsin,  and  large 
parietal  cells  secreting  hydrochloric  acid ;  the  pyloric  glands  secrete  no  acid, 
only  pepsin. 

The  stomach  is  richly  supplied  with  blood  vessels  from  the  coeliac  axis 
and  from  the  splenic  artery.  The  nerves  are  the  vagus  and  the  sym- 
pathetic ;  the  right  supplies  the  posterior,  and  the  left  the  anterior  surface. 

One  of  the  most  important  physiological  aspects  of  the  stomach  lies  in 
its  nervous  mechanism,  because  in  not  a  few  cases  of  disease  it  is  evident 
that  the  nervous  system  exercises  a  profound  effect  on  the  processes  of  the 
stomach,  and  the  interaction  of  both  leads,  in  some  cases,  to  very  great 
disorder.  Although  this  is  so,  the  effect  of  the  nervous  mechanism  of  the 
stomach  is  by  no  means  clear  from  a  physiological  point  of  view.  The 
vagus  nerves,  for  example,  have  been  shown  to  exercise  some  power  over  the 
movements  of  the  organ,  and  a  section  of  both  causes  pallor  of  the  mucous 
membrane  during  digestion.  Stimulation,  however,  of  the  vagus  does  not 
produce  secretion  of  gastric  juice — although  gastric  juice  flows  as  the  result 
of  local  stimulation,  whether  mechanical,  chemical,  or  electrical — yet  the 
flow  is  influenced  by  the  higher  nervous  centres,  since  it  may  be  excited 
reflexly  by  a  flow  of  saliva.  The  stomach,  however,  does  not  possess  a 
direct  motor  nerve  nor  a  direct  secretory  nerve,  but  both  motion  and 
secretion  are  to  some  extent  under  the  influence  of  the  nervous  system. 
When  removed,  the  movements  still  persist  in  an  appropriate  warm 
chamber.  It  has  been  supposed  that  the  local  nervous  mechanism  of  the 
stomach,  as  shown  by  its  automatic  action,  resides  in  Auerbach's  plexus 
and  ganglia,  situated  in  the  muscular  coat. 

In  connection  with  the  nervous  mechanism  of  the  stomach,  vomiting 
must  be  considered.  It  is  a  reflex  effect,  dependent  on  the  excitation 
of  a  centre  in  the  medulla  oblongata.  This  may  be  directly  affected ; 
although  more  usually  it  is  affected  reflexly  by  impulses  either  from  the 
fauces  and  the  surrounding  parts,  or  from  the  internal  organs  by  means  of 
the  visceral  nerves  supplied  to  them.  In  some  cases,  as  when  vomiting 
is  accompanied  by  great  pain,  the  afferent  nerve  is  a  sensory  one. 

The  physiological  processes  which  occur  in  the  stomach  may  be  divided 
into  mechanical,  chemical,  and  absorptive. 

1.  The  movements  of  the  stomach  may  be  divided  into  two  periods. 
In  the  first  period  the  food  is  intimately  mixed  in  the  stomach  by  means 
of  the  circular  and  churning  movements,  the  food  passing  from  the  cardia 
along  the  greater  curvature  and  back  again  along  the  lesser.  After  the 
food  is  swallowed,  this  period  lasts  a  considerable,  although  varying,  time, 


DISEASES  OF  THE  STOMACH.  651 

dependent  chiefly  upon  the  size  of  the  meal.  In  the  second  period  of 
movement  the  semi-digested  food  or  chyme  is  propelled,  probably  en  masse, 
into  the  duodenum,  although  small  portions  of  the  liquid  may  from  time  to 
time  be  expelled.  The  movements  of  the  stomach  are  diminished  by 
violent  exercise  and  strong  emotions,  and  cease  during  sleep. 

2.  The  chemical  processes  of  the  stomach  are  concerned  with  the  action  of 
gastric  juice  on  the  mixed  food — the  proteids,  fats,  and  carbohydrates  taken 
in  the  meal.  The  gastric  juice  possesses  three  actions — first,  it  curdles  milk, 
due  to  the  milk-curdling  ferment,  rennin ;  second,  it  digests  proteids  by 
means  of  pepsin  acting  in  conjunction  with  hydrochloric  acid ;  third,  it 
is  antiseptic  owing  to  the  presence  of  this  acid.  The  gastric  juice  has  no 
action  on  fats  or  on  carbohydrates ;  it  stops  the  action  of  the  saliva  on 
starch,  although  this  goes  on  in  the  stomach,  in  some  cases,  for  a  period  not 
exceeding  forty  minutes.  The  milk-curdling  ferment  precipitates  casein 
in  finely  divided  particles  previous  to  its  digestion  by  the  pepsin  hydro- 
chloric acid.  The  action  of  this  combination  is  exerted  solely  on  proteids 
or  albuminous  substances,  which  are  transformed  from  insoluble  substances, 
or  substances  which  are  not  assimilable  by  the  organism  into  soluble  pro- 
teids— first  into  albumoses,  and  then  peptone.  Gelatin  is  also  digested 
in  the  stomach.  The  result  of  the  action  of  the  gastric  juice  on  the  mixed 
food,  as  well  as  the  movements  of  the  organ,  is  that  the  food  is  partly 
digested  in  the  manner  described,  and  is  finely  divided,  the  fat  being  set 
free  and  floating  on  the  surface  of  the  contents  of  the  organ.  In  addition 
to  this,  an  important  change  takes  place,  from  the  fact  that  the  organic  acids 
are  liberated  from  their  salts  by  means  of  hydrochloric  acid.  The  hydro- 
chloric acid  which  exists  in  the  stomach  contents  is  found  in  two  forms — 
as  chlorides  taken  in  with  the  food ;  and  as  free  hydrochloric  acid,  which 
is  secreted  in  the  gastric  juice.  But  if  there  is  proteid  food  in  the  stomach, 
some  of  this  hydrochloric  acid  combines  loosely  with  it,  while  the  excess 
remains  free,  and  this  is  an  important  point,  because  the  loosely  combined 
hydrochloric  acid  does  not  give  the  colour  tests  of  free  hydrochloric  acid. 

Many  foods  contain  organic  acids  in  the  form  of  salts,  and  especially 
lactic  acid.  Meat,  for  example,  contains  sarcolactic  acid,  and  bread  also 
contains  lactic  acid.  If  both  these  foods  are  taken,  free  lactic  acid  is 
found  in  the  stomach  contents,  as  well  as  free  hydrochloric  acid ;  but  after 
a  short  time,  varying  from  one  to  two  hours,  the  lactic  acid  is  absorbed,  and 
hydrochloric  acid  alone  remains.  The  presence  of  lactic  acid  gave  rise  to  the 
idea  that  it  was  secreted  in  the  gastric  juice.  There  is  but  little  doubt  that 
its  presence  in  any  quantity  actually  inhibits  the  initial  secretion  of  free 
hydrochloric  acid  ;  and,  moreover,  the  pepsin  does  not  act  so  readily  in  the 
presence  of  acetic,  lactic,  and  butyric  acids  as  in  the  presence  of  hydro- 
chloric acid. 

The  duration  of  digestion  of  a  meal  depends  on  many  factors,  some 
of  which  are  inherent  in  the  individual,  others  of  which  are  dependent 
on  the  size  of  the  meal  taken,  with  its  accessories.  The  complete  digestion 
of  a  meal  consisting  of  soup,  a  large  beef  steak,  and  bread  with  water,  takes 
from  five  to  seven  hours,  at  the  end  of  which  time  the  stomach  is  practically 
empty,  the  contents  being  a  little  neutral  liquid  containing  a  few  flakes 
of  mucus.  Smaller  meals  will  require  less  time,  and  the  rapidity  of  the 
early  processes  of  digestion  is  greatly  influenced  by  the  amount  of  alcohol 
taken.  This  retards  the  processes  in  excess ;  but  if  the  quantity  of  alcohol 
taken  be  moderate,  the  digestion  is  completed  in  as  short  a  time  as  when  no 
alcohol  is  taken. 


6  5  2  ALIMENTARY  SYSTEM. 

3.  The  absorptive  processes  which  take  place  in  the  stomach  concern 
sugar,-  salts,  and  proteids.  The  sugar  is  that  which  is  formed  by  the 
action  of  the  saliva  on  starch;  the  salts  are  those  which  are  taken  in 
with  food,  and  there  is  probably  an  active  interchange  between  the  salts 
of  the  blood  and  those  of  the  gastric  contents  during  digestion.  Although 
most  of  the  digested  proteids  are  expelled  into  the  small  intestine,  for  the 
further  action  of  the  pancreatic  juice  and  the  bile,  yet  some  amount  of  the 
albumoses  and  peptone  is  absorbed  by  the  gastric  mucous  membrane,  being 
transformed  during  the  process  into  the  proteids  of  the  blood.  The 
question  of  the  absorption  of  water  in  the  stomach  is  an  important  one, 
and  it  has  been  shown  by  Tappeiner  and  von  Mering,  that  but  little  water 
is  absorbed  in  the  stomach.  This  agrees  with  what  we  know  of  the 
process  of  digestion  in  the  stomach,  since  during  digestion  the  stomach  is 
practically  a  closed  bag,  and  a  certain  proportion  of  water  is  a  necessity 
for  the  proper  carrying  out  of  the  process.  Most  of  the  water  is  absorbed 
in  the  large  intestine. 

The  proper  carrying  out  of  digestion  depends,  as  regards  the  stomach, 
first,  in  the  secretion  of  a  sufficient  amount  of  gastric  juice,  which 
gradually  increases  in  acidity  to  a  percentage  of  0-2  of  hydrochloric 
acid;  second,  on  the  continuance  of  the  movements  of  the  stomach, 
which  begin  as  soon  as  the  food  enters  the  organ,  and  cease  upon  the 
expulsion  of  the  contents  into  the  duodenum;  third,  on  the  character 
of  the  meals,  and  on  a  certain  interval  being  allowed  between  the  meals 
for  the  digestion  to  be  completed.  In  modern  life  there  is  no  doubt 
that  some  individuals  train  their  stomachs  to  eat  large  and  unsuitable 
meals,  but  this  always  leads  eventually  to  disorders  of  digestion  and 
nutrition. 

Methods  of  examination. — The  stomach  contents  have  to  be 
examined  for  the  presence  of  undigested  food ;  the  presence  of  micro- 
organisms, and  of  mucus,  pus,  and  blood ;  the  total  degree  of  acidity, 
and  as  to  the  nature  of  the  free  acids  present,  namely,  hydro- 
chloric, lactic,  butyric,  and  acetic  acid ;  the  presence  of  the  products 
of  digestion,  albumoses  and  peptone;  and  the  presence  of  pepsin  and 
the  curdling  ferment.  For  the  presence  of  bacteria,  a  cover-glass  prepara- 
tion dried  and  stained  with  methylene-blue  is  usually  sufficient.  Sarcina 
is,  however,  best  stained  with  a  very  dilute  solution  of  gentian-violet. 
Mucus  from  the  stomach  is  stringy  and  tenacious,  and  differs  from 
that  coming  from  the  lungs  in  being  unpigmented;  it  may  contain 
streaks  of  blood,  or  the  blood  may  be  diffused  through  it,  giving  a  faint 
yellow  colour.  It  is  soluble  in  liquor  potassse  or  baryta  water,  and  is 
precipitated  from  this  solution  by  acetic  acid.  Pus  is  sometimes  present 
in  vomited  matters,  and  is  recognised,  either  unstained  under  the  micro- 
scope, or  by  making  a  cover-glass  preparation,  and  staining  with  Loffler's 
methylene-blue.  The  detection  of  blood  is,  in  some  cases,  important.  The 
microscope  may  at  once  decide  the  presence  of  blood  corpuscles.  The 
guaiacum  test  may  be  applied,  but  inasmuch  as  it  is  given  by  some 
vegetable  substances,  for  example  potato,  and  by  bile  and  saliva,  it  is  not 
of  much  value  in  detecting  blood  in  vomited  matters.  "  Coffee-ground  " 
vomiting  must  be  diagnosed  from  vomit  containing  bile  or  vegetable- 
colouring  matter.  The  best  test  to  apply  for  the  detection  of  blood  in  this 
case,  is  the  formation  of  haBmin  crystals,  or  the  production  of  Prussian 
blue.  For  the  formation  of  hgemin  crystals,  a  little  of  the  black  sediment 
is  put  on  a  microscope  slide  and  mixed  with  a  little  common  salt.     One  or 


DISEASES  OF  THE  STOMACH.  653 

two  drops  of  glacial  acetic  acid  are  added ;  and  the  specimen  is  covered 
with  a  cover-glass,  and  heated  over  a  spirit-lamp  until  it  bubbles.  The 
hfemin  crystals  are  reddish  brown  and  oblong.  The  test,  however,  may 
fail,  and  the  second  must  be  applied.  To  some  of  the  black  sediment  in  a 
porcelain  capsule  a  small  quantity  of  potassium  chlorate  is  added,  and  a  few 
drops  of  hydrochloric  acid ;  on  heating,  with  the  addition  of  a  few  drops  of 
potassium  ferrocyanide  solution  (5  per  cent.),  Prussian  blue  is  developed, 
if  blood  is  present.  The  patient  must  not,  of  course,  be  taking  any  pre- 
paration of  iron. 

The  total  acidity  of  the  stomach  contents  may  be  due  to  acid  salts, 
to  hydrochloric  acid,  or  to  organic  acids.  Litmus  paper  is  a  test  for  acidity ; 
Congo  red  paper,  which  is  turned  blue  or  violet-black,  is  a  test  of  free 
acidity,  whether  due  to  hydrochloric  acid  or  to  organic  acids.  The  blue 
colour  disappears  on  the  addition  of  ether  in  the  case  of  the  organic  acids, 
but  is  permanent  when  produced  by  hydrochloric,  or  any  other  mineral 
acid.  The  total  acidity  is  estimated  by  taking  20  c.c.  of  the  stomach 
contents,  adding  three  or  four  drops  of  a  saturated  alcoholic  solution  of 
phenolphthalein,  and  diluting  with  water  to  300  c.c.  150  c.c.  of  this  are 
placed  in  each  of  two  flasks,  and  to  one  a  decinormal  solution  of  sodium 
hydrate  is  added,  until  a  red  colour  appears.  The  liquid  is  now  neutralised, 
and  the  determination  may  be  controlled  by  a  second  estimation  in  the 
other  flask.  Each  100  c.c.  of  the  sodium  hydrate  solution  neutralise  0"365 
grm.  of  hydrochloric  acid.  If,  therefore,  50  c.c.  of  the  solution  be  required 
to  neutralise  100  c.c.  of  the  stomach  contents,  the  total  acidity  expressed 
in  terms  of  hydrochloric  acid  is  equal  to  about  0-18  grm.  per  cent. 

Free  acidity  may  be  divided  into  fixed  acidity,  due  to  hydrochloric 
acid  or  lactic  acid ;  and  volatile  acidity,  due  to  butyric  or  acetic  acid. 

Hydrochloric  acid  (other  than  in  combination  as  chlorides)  in  the  gastric 
contents  exists  in  two  forms — in  a  free  state,  and  combined  with  proteids. 
This  latter  combination  does  not  give  the  colour  reactions  which  will  be 
described,  and  it  can  only  be  estimated  by  one  of  the  methods  for  the  total 
estimation  of  hydrochloric  acid.  The  best  tests  for  the  detection  of  free 
hydrochloric  acid  are  two,  which  give  the  same  colour  reaction,  namely, 
Gunsberg's  and  Boas'.  Gunsberg's  solution  is  composed  of  phloroglucin, 
2  grms. ;  vanillin,  1  grm.;  alcohol,  30  c.c.  Boas'  solution  consists  of  5  grins, 
resorcin,  3  grms.  of  cane  sugar,  and  100  c.c.  of  weak  spirit.  Both  tests  are 
applied  in  the  same  way,  namely,  a  drop  of  the  solution  is  mixed  with  a 
drop  of  the  stomach  contents  in  a  white  porcelain  capsule,  and  evaporated 
to  dryness.  If  free  hydrochloric  acid  is  present,  a  rose  colour  is  developed. 
As  little  as  0-05  grm.  per  cent,  may  be  detected  in  this  way.  Lactic  acid, 
the  other  fixed  acid,  is  best  detected  by  shaking  up  the  stomach  contents 
with  an  equal  volume  of  ether ;  on  removing  the  ether  and  allowing  it  to 
evaporate,  the  residue  may  be  dissolved  in  water.  The  tests  to  be  applied 
are — first,  Uffelmann's  reaction.  A  solution  is  made  of  carbolic  acid  (1  to  20) 
10  c.c,  and  water  20  c.c.  One  or  two  drops  of  liquor  ferri  perchloridi  are 
added,  and  the  amethyst  blue  solution  is  changed  to  a  clear  yellow  or 
greenish  yellow  by  as  little  as  O'Ol  per  cent,  of  lactic  acid.  A  second  test  is 
made  by  adding  one  or  two  drops  of  liquor  ferri  to  50  c.c.  of  water.  This 
solution  is  almost  colourless,  and  is  made  yellow  by  lactic  acid.  Volatile 
acids  may  be  detected  by  the  smell,  that  of  butyric  acid  being  very 
characteristic ;  or  by  the  formation  of  their  respective  ethers,  namely,  by 
adding  to  the  stomach  contents  a  small  quantity  of  alcohol,  2  drops  of 
sulphuric  acid,  and  heating.     Butyric  ether  has  the  smell  of  pine-apple 


654  ALIMENTARY  SYSTEM. 

rum ;  acetic  ether  has  the  smell  of  new-mown  hay.  Acetates  give  also 
a  blood-red  colour  with  a  solution  of  perchloride  of  iron.  For  the  methods 
of  determination  of  the  total  quantity  of  hydrochloric  or  organic  acids, 
other  works  should  be  consulted. 

The  presence  of  digestive  products  (albumoses  and  peptone)  in  the 
stomach  contents  is  detected  by  the  biuret  reaction,  which  is  a  pink 
colour,  developed  on  adding  a  trace  of  solution  of  copper  sulphate  and  an 
excess  of  potash  to  the  liquid. 

The  activity  of  the  gastric  juice  and  the  power  of  the  stomach  to 
manipulate  food  and  to  empty  itself  in  a  certain  time  are  determined  by 
means  of  a  test  meal.  The  secretion  of  the  gastric  juice  may  be  tested  by 
using  Ewald's  test  breakfast,  consisting  of  a  little  over  1  oz.  of  bread  and 
about  12  oz.  of  water.  This  is  removed  by  means  of  the  stomach  sound  in 
from  half  an  hour  to  an  hour;  and  the  presence  of  hydrochloric  acid  is 
detected  in  the  manner  previously  described.  A  better  test  meal,  which 
also  tests  the  mechanical  power  of  the  stomach,  is  that  of  Leube,  and 
consists  of  a  little  soup,  5  oz.  of  beef  steak,  and  a  small  bread  rolL-  The 
patient  must  be  fasting,  and  must  rest  after  the  meal.  In  five  hours  the 
stomach  contents  are  removed  by  the  sound.  Usually  the  meal  is  in 
greater  part  digested,  and  in  seven  hours,  in  healthy  individuals,  it  is 
completely  so.  It  is  in  some  cases  advisable  to  use  only  white  of  egg  and 
milk  as  the  test  meal,  and  in  most  cases  to  remove  the  stomach  contents 
in  two  and  a  half  hours,  not  in  five. 

The  use  of  test  meals  is  chiefly  limited  to  intractable  cases  of  functional 
disorder  of  the  stomach,  in  order  to  decide  exactly  what  function  is 
deficient,  or  to  see  whether  the  diminution  of  the  action  of  the  stomach 
is  permanent,  as  in  cases  of  gastric  catarrh.  In  ulcer,  and  in  the  majority 
of  cases  of  cancer,  the  test  meal  is  inapplicable.  In  the  first  case  the 
sound  must  not  be  passed,  and  in  the  second  place  a  test  meal  is  un- 
necessary, as  it  is  in  the  majority  of  cases  of  functional  disorder.  The 
stomach  sound  is  not  to  be  passed  when  there  are  any  signs  or  symptoms 
of  thoracic  aneurysm;  when  there  is  a  severe  wasting  disease,  or  one 
tending  to  syncope,  such  as  advanced  pulmonary  tuberculosis  or  serious 
cardiac  disease,  when  there  has  been  recent  bleeding  from  any  part,  or  in 
cases  of  great  debility,  or  in  advanced  age. 


GASTEIC  INDIGESTION". 

By  functional  disorder  of  the  stomach  is  meant  the  condition  of  in- 
digestion of  food  which  results  from  a  change  in  the  activities  of  the 
stomach.  Indigestion  of  the  food  also  occurs  in  organic  disease  of  the 
organ;  such  as  congestion,  catarrh,  new  growth,  or  long-standing  ulcer. 
In  the  class  of  cases  now  under  consideration,  there  are  no  organic  changes 
in  the  organ,  or  none  of  any  permanent  character. 

Cases  of  functional  indigestion  may  be  divided  into  three  classes. 
Although  in  all,  food  is  the  direct  inciting  cause  of  the  disorder,  yet  in  the 
first  case,  which  I  have  elsewhere  called  gastric  irritation,  food  plays  a 
very  large  part  in  the  etiology  of  the  disorder.  (2)  In  the  second  class 
of  cases,  which  I  have  called  gastric  insufficiency,  there  is  a  primary 
functional  defect  in  the  stomach,  usually  resulting  from  some  general 
disorder,  such  as  ansemia,  gout,  or  acute  infective  disease.  (3)  In  the  third 
class,  which  will  be  discussed  under  the  heading  of  nervous  dyspepsia  or 


DISEASES  OF  THE  STOMACH.  655 

neuroses  of  the  stomach,  the  symptoms  are  mainly  those  referable  to  the 
nervous  system. 

All  these  classes  of  cases  run  into  each  other,  and  may  at  one  time  or 
another  present  symptoms  which  are  very  similar.  A  distinction  can, 
however,  be  made  in  the  majority  of  instances  from  the  history  of  the 
patient,  the  general  condition  present,  or  from  the  results  of  treatment. 

Many  different  classifications  have  been  made  of  dyspepsia,  such  as 
acid  dyspepsia,  atonic  dyspepsia,  flatulent  dyspepsia,  and  so  on.  These, 
however,  appear  to  me  very  unpractical  divisions,  and  the  classification  I 
have  used  has  been  of  great  service  to  myself  personally,  both  in  the 
recognition  and  in  the  treatment  of  functional  disorder  of  the  stomach. 

Gastric  Irritation. 

In  gastric  irritation  the  symptoms  and  the  examination  of  the  process 
of  digestion  in  the  stomach  show  the  results  of  irritation,  in  which  not  only 
the  secretion  of  the  gastric  juice  is  affected,  but  also  the  motor  activity  of 
the  organ,  the  blood  supply  during  digestion,  and  the  innervation. 

Etiology. — Under  the  heading  of  gastric  irritation  comes  by  far  the 
largest  number  of  cases  of  functional  disorder  of  the  organ ;  and  what  may 
be  considered  as  nervous  dyspepsia  is  really  only  part  of  gastric  irritation 
with  a  prominence  of  nervous  symptoms.  It  includes  those  cases  which 
are  usually  described  as  acid  dyspepsia.  It  is  usually  primary,  but  it  may 
be  associated  with  certain  diseases  or  general  conditions  of  the  body.  As 
a  functional  disorder  it  may  last  a  considerable  time,  even  years,  and  one 
of  its  features  is  that  there  are  periods  of  quiescence,  during  which 
digestion  is  fairly  well  performed,  and  periods  of  exacerbation,  in  which 
the  symptoms  of  dyspepsia  are  almost  intolerable.  It  may,  however,  lead 
to  gastric  catarrh,  inasmuch  as  the  repeated  irritation,  which  produces 
functional  disorder,  not  infrequently  leads  to  inflammation. 

Age  and  Sex. — It  may  occur  at  any  age :  in  the  infant,  whether  fed 
by  the  wet  nurse  or  by  the  bottle,  in  the  child,  in  adult  life,  and  in  old  age. 
Sex  has  but  little  influence,  except  that  in  adult  life  the  more  direct  cause 
of  the  condition  is,  in  women,  excessive  tea-drinking,  and  in  men,  excess  of 
food,  as  well,  as  of  food  accessories,  especially  alcohol. 

Temperament. — Those  who  may  be  described  as  of  a  nervous  tempera- 
ment are  especially  prone  to  gastric  irritation;  such  individuals  being 
particularly  affected  by  periods  of  worry,  anxiety,  or  excitement. 

Heredity  plays  a  more  important  part  in  nervous  dyspepsia  than  it 
does  in  simple  gastric  irritation. 

Climate  and  race  have  no  influence,  except  as  regards  the  character 
of  the  food  eaten.  The  most  important  factor  in  the  etiology  of  gastric 
irritation  concerns  the  food  and  the  mode  of  living  of  the  individual.  For 
a  healthy  existence  a  sufficiency  of  food  and  of  exercise  and  a  congenial 
occupation  are  necessary.  Insufficiency  of  food,  even  with  much  exercise, 
leads  to  the  disorder.  More  frequently,  however,  an  insufficiency  of 
exercise  is  the  cause,  leading,  as  it  does  very  frequently,  to  the  eating  of  a 
large  quantity  of  food  at  meals,  and  the  taking  of  unsuitable  quantities  of 
alcohol  and  tea.  Thus  the  disorder  is  met  with  as  frequently  among  the 
well-to-do,  or  the  professional  classes,  who  lead  sedentary  lives,  as  amongst 
the  poor,  as  for  example  the  sempstress  who  works  ten  hours  a  day  in  a 
badly  ventilated  room.  With  regard  to  food,  the  arrangement  of  meals 
is  of  importance.     A  large  meal  ought  to  be  followed  by  a  period  of  bodily 


656  ALIMENTARY  SYSTEM.   , 

rest  and  recreation  (not  sleep),  and  should  not  be  succeeded  by  another 
large  meal  within  five  hours.  Meals  eaten  hurriedly  lead  to  gastric  irrita- 
tion, as  also  does  work,  mental  or  bodily,  directly  after  a  heavy  meal. 
Large  meals  eaten  before  going  to  sleep  are  a  factor  also. 

An  important  factor  to  be  considered  is  imperfect  mastication,  which 
may  be  either  due  to  toughness  of  the  food,  to  the  habit  of  rapid  eating 
and  bolting  of  the  food,  to  pain  caused  by  decayed  teeth,  or  to  the  absence 
of  teeth.  The  stomach  cannot  for  long  cope  with  unmasticated  food.  The 
bulk,  composition,  and  reaction  of  food  are  also  important.  Excess  of. 
food,  as  has  been  stated,  gives  the  stomach  no  rest,  and  from  its  mere  bulk 
it  produces  disorder  by  throwing  too  much  work  on  the  stomach,  so  that 
during  the  day  the  stomach  is  never  empty ;  and  although  there  may  be 
at  first  hypersecretion  of  the  organ  to  enable  the  food  to  digest,  finally  the 
secretion  becomes  deficient  with  repeated  large  meals,  and  the  movements 
of  the  organ  inefficient. 

As  regards  the  composition  of  the  food,  a  certain  amount  of  proteids, 
carbohydrates,  fats,  salts,  and  water,  are  necessary  in  the  daily  diet  in  order 
to  maintain  nutrition.  In  the  dietary  of  the  well-to-do  an  excess  of  meat 
is  a  frequent  cause  of  gastric  irritation ;  in  that  of  the  poorer  classes,  an 
excess  of  vegetable  food  has  the  same  effect.  A  large  amount  of  meat  leads 
to  hyperacidity  of  the  stomach  contents,  which  is  partly  due  to  an  excessive 
secretion  of  hydrochloric  acid,  and  partly  to  the  liberation  of  sarcolactic 
acid  contained  in  the  meat.  A  large  amount  of  meat,  therefore,  leads  to 
excessive  secretion  of  gastric  juice,  and  this,  in  time,  to  disorder.  On  the 
other  hand,  an  excessive  amount  of  vegetable  food,  which  is  not  digested  in 
the  stomach,  irritates  the  organ  from  its  mere  bulk,  and  more  especially 
since  such  food  frequently  contains  an  excess  of  organic  acids  and  salts, 
which  increase  the  acidity,  as  well  as  a  certain  amount  of  cellulose,  which 
is  not  digested  in  any  part  of  the  stomach  or  intestines.  The  amount  of 
cellulose  contained  in  different  food-stuffs  varies,  e.g.  fine  wheaten  flour 
contains  0*29  per  cent,  by  weight ;  and  whole-meal  flour,  1*9  per  cent.;  barley 
and  rice  flour,  about  0-5  per  cent.;  potatoes,  0*69  per  cent.;  spinach  and  cauli- 
flower, about  1  per  cent.;  and  fine  oatmeal  contains  as  much  as  1/86  per  cent. 

As  regards  the  chemical  reaction  of  food,  all  that  need  be  said  is  that 
food  must  not  be  taken  too  acid.  The  cooking  of  food  is  important  as 
regards  its  digestibility.  Bad  cooking  of  food  is  a  frequent  cause  of  gastric 
irritation,  either  by  making  the  food  tough,  or  by  destroying  the  flavours 
which  are  developed  during  good  cooking ;  or,  as  in  the  case  of  starch,  by 
not  loosening  the  grains  of  which  the  starch  is  composed.  Of  as  much 
importance  in  the  production  of  gastric  irritation  as  food,  are  the  food 
accessories,  such  as  alcoholic  drinks,  tea,  and  coffee.  To  some  extent  these 
accessories  are  useful  in  digestion ;  taken  in  excess,  however,  they  act  as 
irritants,  their  action  in  this  respect  being  slow  and  extended  over  a  long 
period  of  time.  Alcoholic  drinks,  especially  beer,  port,  sherry,  hock, 
burgundy,  and  claret,  delay  the  chemical  processes  of  digestion,  and  lead  to 
an  increased  organic  acidity  of  the  stomach  contents.  Alcohol  itself,  taken 
with  the  meal,  has  this  action,  though  in  moderate  quantities  the  action  is 
not  without  benefit,  since  the  process  of  digestion  is  slow  at  first,  and  thus 
more  perfectly  performed ;  and  later  on  the  alcohol  stimulates  the  secretion 
of  gastric  juice,  and  thus  helps  the  digestion  of  a  large  meal.  The  taking 
of  alcoholic  drinks  does  less  harm  when  taken  with  meals  than  when  taken 
on  an  empty  stomach ;  but  they  may  cause  bad  effects  in  some  individuals, 
even  when  taken  in  moderate  quantities. 


DISEASES  OF  THE  STOMACH.  657 

The  final  result  of  an  excess  of  food  or  of  food  accessories  on  the  stomach, 
is  to  cause  the  delay  of  food  in  the  stomach  by  affecting  the  movements  of 
the  organ,  as  well  as  to  cause  the  hypersecretion  of  hydrochloric  acid 
which  leads  to  definite  symptoms. 

Relation  to  other  diseases.— Gastric  irritation  may  be  present  in 
cancer  of  the  stomach,  as  well  as  in  infective  disorders,  such  as  tuberculosis, 
chronic  malaria,  and  in  convalescence  from  typhoid  fever,  scarlet  fever, 
measles,  rheumatic  fever,  and  influenza.  Its  presence  in  these  conditions 
is  frequently  preceded  by  some  effect  on  the  stomach,  altering  its  functions, 
which  brings  it  into  relation  with  the  cases  of  gastric  insufficiency. 

Pathology. — The  pathological  conditions  present  in  gastric  irritation 
are  not  associated  for  a  very  long  period  with  any  organic  changes  in  the 
glands  or  in  the  muscular  coats  of  the  organ.  They  may  be  divided — (1) 
into  the  condition  of  acidity  of  the  stomach  contents ;  (2)  into  the  condition 
of  the  movements ;  and  (3)  into  the  condition  of  digestion. 

1.  In  such  cases  there  is  a  secretion  of  very  acid  gastric  juice  during  diges- 
tion, and  this  may  continue  after  digestion  is  completed;  the  organ  may  thus 
never  be  free  from  some  acid  liquid  and  remnants  of  food.  Cases,  however, 
differ,  as  in  some  a  large  amount  of  acid  is  secreted  in  an  hour  or  an  hour 
and  a  half  from  the  time  of  taking  the  meal ;  and  this  continues  during 
the  process  of  digestion,  ceasing  towards  the  end.  In  other  and  more 
severe  cases  the  secretion  continues  even  after  the  mass  of  food  has  been 
expelled  into  the  duodenum.  The  degree  of  acidity  which  has  been  found 
is  far  above  the  normal.  It  may  be  0*3  or  032  per  cent.  (Eeichmann),  or 
even  higher,  the  normal  being  0'2  per  cent.  The  examination  of  the 
stomach  contents  of  222  persons  during  fasting  showed  that  they  were 
acid,  the  acidity  being  due  to  hydrochloric  acid  in  179  or  81  per  cent. 
(Jaworski).  The  continued  irritation  of  the  stomach  by  an  excess  of  acid 
causes  an  increased  secretion  of  mucus,  at  any  rate  in  the  early  stages  of 
the  disorder.  This,  however,  is  not  a  feature  of  gastric  irritation,  as  it  is 
in  gastric  catarrh. 

2.  The  movements  of  the  stomach  are  at  first  excited  in  gastric  irrita- 
tion chiefly  by  the  excess  of  food,  as  well  as  by  the  hyperacidity ;  so  that 
the  increased  activity  leads  to  more  rapid  digestion  of  food.  This  may 
be  so  well  marked  that  the  food  is  too  rapidly  expelled  from  the  organ, 
leading  to  great  distress.  In  other  cases  there  is  well-marked  spasmodic 
contraction  of  the  stomach,  which  occurs,  particularly,  when  irritant 
articles  of  diet  are  taken ;  a  spasm,  which  is  only  relieved  by  the  expulsion 
of  the  contents  of  the  organ  through  the  duodenum  or  by  way  of  the 
gullet.  In  not  a  few  instances,  however,  gastric  irritation  is  associated 
with  atony  of  the  organ  and  some  degree  of  dilatation. 

3.  The  congestion  which  occurs  in  gastric  irritation  is  a  temporary 
condition,  being,  like  the  hyperacidity,  an  exaggeration  of  the  normal 
condition  of  the  organ  during  digestion.  Its  continuance  renders  the  stomach 
more  sensitive ;  in  many  cases  it  is  directly  associated  with  the  pain  experi- 
enced during  digestion. 

Symptoms. — The  mode  of  onset  of  gastric  irritation  is  not  commonly 
acute ;  it  is  usually  insidious,  the  symptoms  being  very  gradual  in  their 
onset,  at  first  being  caused  by  repeated  slight  indiscretions  in  diet  or 
irregularity  in  the  mode  of  living.  In  its  course,  gastric  irritation  is 
charterised  by  periods  of  only  slight  disorder,  intervening  on  other 
periods  of  more  or  less  acute  exacerbation. 

Acute  gastric  irritation  occurs  usually  as  the  result  of  large  meals  or 
vol.  1. — 42 


658  ALIMENTARY  SYSTEM. 

of  irritating  food.  It  is  frequently  referred  to  euphemistically  as  a  "  bilious 
attack,"  whereas  in  reality  it  is  a  food  debauch  affecting  the  stomach.  The 
symptoms  which  occur  in  such  cases  are  not  developed  during  the  partak- 
ing of  a  meal,  nor  for  perhaps  two  hours  or  more  afterwards ;  then  a  sense 
of  fulness  and  discomfort  is  experienced  in  the  epigastrium,  accompanied 
by  nausea,  and  frequently  terminating  in  the  ejection  of  the  whole  of  the 
contents  of  the  organ,  which  gives  relief.  The  vomited  matters  are  hyper- 
acid, the  acidity  being  due  to  an  excess  of  hydrochloric  acid.  During  the 
day  following  this  occurrence  the  appetite  is  lost,  and  frequently  loose 
motions  are  passed.  Acute  dilatation  of  the  organ  may  result  from  a 
single  large  meal,  but  in  these  cases  there  is  some  chronic  disease  already 
present. 

The  physical  signs  which  are  present  in  acute  gastric  irritation  show 
that  the  stomach  is  firmly  contracted,  its  contents  being  felt  as  a  round 
ball  in  the  epigastrium.  There  is  little  or  no  tenderness,  but  manipulation 
may  cause  eructation  of  gas,  or  even  vomiting.  There  is  a  thickly-coated 
tongue,  with  a  lingering,  nauseous  taste  in  the  mouth,  lassitude,  and 
frequently  headache,  while  the  complexion  is  pale. 

Chronic  irritation. — Chronic  irritation  is  the  more  common  disorder, 
and  comprises  by  far  the  larger  proportion  of  cases  of  functional  disorder 
of  the  stomach.  The  symptoms  which  are  observed,  and  which,  as  a  rule, 
preserve  their  individual  features  in  each  particular  case,  may  be  divided 
into  those  which  are  general  and  those  referable  to  the  stomach.  The 
latter  are  shown  in  a  sense  of  fulness,  weight,  and  oppression  in  the  chest 
after  eating,  as  well  as  pain  in  the  back  and  over  the  angles  of  the  scapulae. 
The  more  general  symptoms  are  referable  to  the  nervous  system,  such  as 
headache,  palpitation,  drowsiness,  mental  depression,  sleeplessness,  vertigo, 
hiccough.  The  symptoms  referable  to  the  stomach  always  appear  in 
relation  to  the  food,  coming  on  at  various  times  after  the  meal,  and  are 
most  marked  after  the  principal  meal  of  the  day,  or  in  the  evening  when 
the  stomach  has  had  the  three  daily  meals  to  digest. 

The  sense  of  weight,  fulness,  and  oppression  in  the  epigastric  region 
may  come  on  directly  after  eating,  but  is  often  delayed  for  half  an  hour, 
or  for  one  or  two  hours,  and  it  may  then  last  until  the  next  meal,  which 
relieves  it.  Pain  in  the  chest  and  between  the  shoulders  bears  a  similar 
relation  to  the  meal.  The  delayed  onset  of  the  pain  after  the  meal  is  due 
to  the  fact  that  at  that  time  the  stomach  has  secreted  an  amount  of 
excessively  acid  gastric  juice,  sufficient  to  irritate  the  mucous  membrane. 
The  continuance  of  the  pain  for  long  periods  is  ascribable  to  the  delay  of 
food  in  the  organ,  although  this  is  not  always  the  case,  since  the  stomach 
may  be  rapidly  emptied  by  an  over-excitable  muscular  coat,  and  the 
symptoms  continue  as  the  result  of  continued  secretion  of  hyperacid  gastric 
juice.  After  a  time  these  sensations  are  more  or  less  continuous,  the 
stomach,  in  fact,  being  never  at  any  time  empty. 

Flatulence  is  a  frequent  symptom  in  gastric  irritation.  It  is  not  due 
to  bacterial  fermentation  of  the  food,  but  may  be  caused  by  one  or  other 
of  the  following  conditions  : — 

It  may  be  due  to  the  accumulation  of  small  quantities  of  gas,  chiefly 
carbonic  acid,  which  are  generated  from  time  to  time  in  the  stomach  and 
small  intestine,  and  which  are  not  propelled  onwards  in  the  normal  manner, 
but  are  eructated.  This  form  of  flatulence  is  common  in  the  middle-aged 
and  the  old. 

Flatulence  may  be  due  to  swallowed  air,  or  to  swallowed  saliva,  the 


DISEASES  OF  THE  STOMACH.  659 

carbonates  of  which  are  decomposed  by  the  acids  of  the  gastric  juice,  setting 
free  carbonic  acid. 

It  may  be  due  to  the  regurgitation  of  pancreatic  juice  into  the 
stomach,  the  carbonates  of  which  are  decomposed,  setting  free  carbonic 
acid.  This  occurs  in  naccidity  of  the  stomach  walls  with  patency  of  the 
pylorus.  In  some  cases  it  has  been  supposed  that  large  quantities  of  gas 
may  be  discharged  from  the  blood  into  the  stomach  and  intestines,  and 
then  be  eructated. 

Vomiting  is  a  frequent  symptom  in  the  acute  exacerbations  of  chronic 
gastric  irritation ;  the  vomiting  is  in  this  case  directly  due  to  the  presence 
of  irritating  food  in  the  stomach,  as  well  as  to  the  excessive  secretion  of 
hydrochloric  acid,  and  occurs  more  commonly  in  patients  with  excitable 
nervous  systems,  or  in  the  aneemic.  In  some  cases,  vomiting  may  occur 
after  every  meal ;  sometimes  directly  after  a  meal,  sometimes  not  for  one 
or  two  hours.  It  may  also  occur  in  the  morning,  in  cases  where  heavy 
suppers  have  been  taken  before  going  to  bed.  Vomiting  is  kept  up  by 
continued  indiscretions  in  diet,  and  is  cured  by  proper  dieting.  The 
vomited  matters  may,  in  some  cases,  contain  a  little  mucus,  but  it  con- 
sists chiefly  of  digesting  food,  and  contains  pex->tones.  It  is  very  acid, 
the  acidity  being  due  mainly  to  hydrochloric  acid,  which  is  usually  present 
to  an  amount  of  over  0*3  grm.  per  cent.  This  hyperacidity  is  sometimes 
absent.     Active  pepsin  is  always  present. 

Cases  of  gastric  irritation  may  continue  with  the  symptoms  above 
described  for  many  years,  and  may  have  omissions  of  greater  or  less 
duration,  and  exacerbations,  which  render  the  sufferer's  life  unendurable  for 
a  time,  causing,  in  some  cases,  restlessness  and  mental  inactivity  during 
the  day.  By  proper  treatment,  complete  recovery  is  the  rule ;  but,  on  the 
other  hand,  through  neglect,  permanent  injury  may  be  done,  so  that  the 
digestion  becomes  impaired.  Catarrh  of  the  stomach  may  result,  with  a 
profound  diminution  in  the  functions  of  the  organ ;  or  permanent  dilatation 
of  the  stomach  may  occur,  with  symptoms  which  will  be  discussed  later. 

The  appetite  may  be  normal  or  increased,  and  may  even  be  voracious. 
Later  on  it  becomes  capricious,  and  long-continued  gastric  irritation  leads 
to  diminution  of  the  appetite.  The  tongue  is  frequently  coated,  especially 
in  the  morning  on  waking,  and  there  is  a  nasty  taste  in  the  mouth,  which 
is  clammy  from  mucus.  Salivation  frequently  occurs  from  gastric  irrita- 
tion ;  usually  after  meals,  at  the  time  of  greatest  acidity  for  the  stomach 
contents.  In  some  cases,  on  the  other  hand,  chiefly  of  long  duration,  there 
is  a  greatly  deficient  secretion  of  saliva,  so  that  the  mouth  is  always  dry 
(xerostomia),  which  adds  greatly  to  the  distress  of  the  patient.  Constipa- 
tion is  the  rule  in  gastric  irritation ;  the  bowels  being  opened  once  in  one 
or  two  days,  or  sometimes  not  for  a  week,  or  only  with  medicine.  Fre- 
quently, however,  there  is  an  alternating  condition  of  constipation  and 
diarrhoea ;  there  being  one  or  two  days  of  looseness  of  the  bowels,  followed 
by  constipation.  Lienteric  diarrhoea  may  also  occur,  coming  on  directly 
after,  or  soon  after,  a  meal.  This  condition  appears  to  be  associated  with 
irritability  of  the  muscular  coat,  whereby  the  food  is  rapidly  discharged 
into  the  small  intestine. 

The  chief  changes  that  occur  in  the  urine  are  a  tendency  to  alkalinity, 
a  diminution  in  the  quantity  of  urine  secreted,  and  an  excessive  excretion 
of  phosphates.  Albuminuria  is  rarely  present ;  but  albumoses  may  be 
found  in  the  urine. 

Effect  on  general  nutrition. — As  a  rule  the  patients  subject  to  this 


660  ALIMENTARY  SYSTEM. 

disorder  do  not  waste,  at  any  rate  for  some  time ;  but  this  is  explained 
by  the  fact  that  there  is  more  than  sufficient  hydrochloric  acid  and  pepsin 
to  digest  the  food  in  the  stomach,  and  the  small  intestine  is  normal ;  but 
long-continued  gastric  irritation  leads  to  pallor,  flabbiness  of  the  muscles, 
and  to  increased  myotatic  irritability.  When  wasting  occurs,  it  is  naturally 
associated  with  some  dilatation  of  the  organ,  or  with  prolonged  diarrhoea. 
The  loss  of  flesh,  however,  is  not  progressive.  The  course  of  the  disease 
goes  from  bad  to  worse,  rendering  the  patient's  life  utterly  miserable, 
if  it  be  not  treated.  Patients  are  very  apt,  during  the  periods  of  relief 
from  symptoms,  to  commit  indiscretions  in  diet,  which  bring  on  another 
attack,  and  so  keep  up  the  disorder.  There  is,  however,  no  disease 
which  is  more  amenable  to  treatment  in  its  early  stages.  The  results  of 
untreated  gastric  irritation  are  gastric  catarrh  and  permanent  dilatation 
of  the  organ. 

Diagnosis,  treatment. — These  are  considered  under  Neuroses  and 
Catarrh. 

Gastric  Insufficiency. 

G-astric  insufficiency  is  a  condition  in  which  the  functions  of  the 
stomach  are  diminished.  In  prolonged  gastric  irritation  this  is  the  case. 
It  is  also  the  case  in  catarrh  and  in  cancer  of  the  organ. 

Etiology. — The  term  "insufficiency"  is  applied  more  to  those  cases 
in  which  the  disorder  of  the  organ  follows,  or  is  associated  with  certain 
diseases ;  and  from  a  practical  point  of  view,  this  distinction  from  gastric 
irritation  is  of  some  importance.  The  symptoms  are  directly  brought  out 
by  the  presence  of  food  in  the  organ ;  yet  irritation  is  not  the  direct  cause 
of  the  primary  condition  of  the  stomach,  as  in  gastric  irritation.  The  general 
depression  of  functions  which  occurs  in  those  who  lead  a  sedentary  life,  with 
much  mental  work,  affects  the  stomach,  leading  to  deficient  activity ;  and 
this  occurs  more  readily  towards  the  middle  period  of  life  in  both  men  and 
women.  In  old  age  the  functions  are  diminished  generally,  and  a  smaller 
amount  of  food  is  taken  than  in  the  vigorous  period  of  life.  In  women,  at 
the  menopause,  extreme  insufficiency  is  frequently  observed,  as  well  as  in 
prolonged  lactation.  In  young  adults,  however,  some  recognisable  morbid 
condition  of  the  body  is  present.  These  may  be  divided  into  two  classes. 
Non-febrile  conditions,  such  as  continued  haemorrhage,  from  whatever 
cause,  whether  rectal  or  uterine ;  prolonged  suppuration,  as  well  as 
syphilis  and  tuberculosis ;  and  all  the  conditions  which  lead  to  ansemia 
predispose  to  or  actually  induce  gastric  insufficiency. 

A  state  of  fever  diminishes  the  activity  of  the  stomach,  and  during 
convalescence  the  return  of  function  is  usually  slow.  Indiscretions  in  diet 
at  this  period  may  lead  to  chronic  gastric  disturbances,  shown  chiefly  by 
dilatation  (deficient  motor  activity),  or  by  a  deficiency  of  the  chemical 
processes  of  digestion.  It  is  observed  after  typhoid  fever,  scarlet  fever, 
rheumatic  fever,  measles,  and  influenza,  and  is  a  frequent  accompaniment 
of  progressing  pulmonary  tuberculosis. 

Clinically,  gastric  insufficiency  may  perhaps  be  divided  into  cases 
which  are  temporary,  and  those  which  are  permanent,  the  permanent  cases 
being  due  to  organic  changes  in  the  walls  of  the  stomach,  whether  atrophy, 
inflammation,  or  new  growth. 

Pathology. — In  gastric  irritation,  in  response  to  the  stimulus  of 
food,  there  is  a  deficient  secretion  of  the  gastric  juice  and  deficient  motor 
activity,  both  functions  failing  before  the  meal  is  digested.     This  leads  to 


DISEASES  OF  THE  STOMACH.  66 i 

great  delay  of  the  food  in  the  organ,  and  subsequent  dilatation.  The  food 
which  remains  may  undergo  bacterial  fermentation,  although  this  is  not 
common. 

Symptoms. — The  symptoms  which  are  observed  in  gastric  insuffi- 
ciency are  induced  by  the  food  which  is  taken,  and  food  acts  as  a 
constant  irritant  to  the  organ.  They  come  on  directly  after  a  meal,  and  if 
continued  large  meals  are  taken,  they  last  the  whole  day  through,  and 
sometimes  during  the  night.  There  is  usually  a  sense  of  epigastric  fulness 
and  of  oppression  on  the  chest,  which  may  be  associated  with  dyspnoea. 
Flatulence  is  a  constant  symptom,  and  is  as  a  rule  due  to  one  or  other  of 
the  causes  mentioned  under  gastric  irritation  (p.  654).  It  is  usually 
associated,  however,  with  moderate  dilatation  of  the  organ.  Acid  eructa- 
tions do  not  usually  occur,  and  vomiting  is  not  a  symptom. 

Keflex  symptoms  are  extremely  common  in  gastric  insufficiency,  and  are 
chiefly  nervous,  due  partly  to  the  excitability  of  the  nervous  system,  and 
partly  to  the  condition  of  anaemia  present.  Keflex  pain  is  common,  as  well  as 
tenderness,  most  frequently  in  the  lower  part  of  the  left  axilla.  This  local- 
ised pain  is  almost  always  associated  with  flatulence.  Headache  is  common, 
as  well  as  drowsiness  after  meals,  sleeplessness,  lassitude,  disinclination  to 
exertion;  mental  inaptitude  and  apathy,  and  a  melancholy  view  of  life. 
The  face  is  often  pale  and  anxious-looking ;  the  complexion  may  be  muddy. 
The  appetite  is  always  diminished,  and  the  tongue  is  broad,  pale,  flabby, 
and  tooth-indented,  but  is  not  usually  coated.  Constipation  is  the  rule. 
In  gastric  irritation,  looseness  of  the  bowels  may  be  present,  owing  to  the 
irritation  of  scybala  in  the  colon.  The  pulse  is  feeble,  not  very  frequent, 
but  regular.  The  effect  on  general  nutrition  of  gastric  insufficiency  is  more 
marked  than  in  the  case  of  gastric  irritation.  Wasting  is  very  common, 
or,  if  wasting  is  not  present,  the  muscles  are  very  flabby,  and  may  show 
myotatic  irritability.  Gastric  insufficiency  may  be  a  permanent  condition 
in  old  age,  or  in  those  who  have  inherited  a  weak  digestion.  When  it 
occurs  in  febrile  disorders,  it  is  highly  amenable  to  treatment,  but  if 
neglected,  leads  to  great  dilatation  of  the  organ. 

Diagnosis,  treatment. — These  are  considered  in  the  following 
section. 

Nervous  Dyspepsia. 

The  cases  which  may  be  included  under  this  heading  are  those  in  which, 
while  there  are  stomach  symptoms  of  greater  or  less  variety,  there  is  a 
special  prominence  of  symptoms  referable  to  the  nervous  system.  These 
nervous  symptoms  belong  to  two  categories  —  in  one,  the  prominent 
symptoms  are  referred  to  the  stomach  region;  in  the  other,  they  are 
reflex,  and  may  aptly  be  called  "  gastric  reflexes." 

Etiology. — Nervous  dyspepsia  occurs  more  particularly  in  those  who 
possess  what  is  called  a  nervous  temperament ;  to  speak  more  accurately, 
in  those  in  which  a  slight  stimulus  produces  a  large  response  from  the 
central  nervous  system ;  so  that  in  these  cases  there  is  an  over-excitability 
of  the  central  nervous  system.  The  stomach,  as  has  been  said,  is  connected 
to  the  central  nervous  system  by  means  of  the  vagus  nerves,  and  by  the 
sympathetic  nerves  which  come  from  the  dorsal  region.  The  vagus  con- 
tains two  sets  of  fibres,  both  afferent  and  efferent,  and  although  its  direct 
influence  on  the  functions  of  the  stomach  in  health  is  not  very  profound, 
yet  it  may  be  considered  as  the  chief  conductor  of  impulses  in  those  cases 
of  disease  in  which  symptoms  referable  to  the  nervous  system  are  pro- 


662  ALIMENTARY  SYSTEM. 

minent.  There  is  not  only  an  increased  excitability  of  the  central  nervous 
system  in  these  cases,  but  also  irritability  of  the  nerve-endings  in  the 
stomach.  Nervous  dyspepsia  may  indeed  be  considered  as  one  of  the  mani- 
festations of  the  nervous  conditions  which  are  described  as  hysteria  or 
neurasthenia,  and  hypochondriasis. 

Pathology. — The  condition  of  the  stomach  in  nervous  dyspepsia  is  a 
very  variable  one,  both  as  regards  the  secretion  of  gastric  juice  and  the 
motor  activity  of  the  organ.  Variability  constitutes  one  of  the  most  im- 
portant points  in  diagnosis.  Thus  in  an  individual  case  there  may  be  at 
one  time  an  excessive  secretion  of  hydrochloric  acid,  and  at  another  a 
diminished  secretion;  in  another  case  the  chief  change  may  be  one  of 
deficient  motor  activity,  showing  itself  in  more  or  less  dilatation  of  the 
organ,  as  well  as,  at  intervals,  irritability.  At  one  time  in  such  patients  the 
processes  of  digestion  may  be  exceedingly  good,  at  another  greatly  deficient. 

Symptoms. — Symptoms  referable  to  the  nervous  system  may  be 
present  in  ordinary  cases  of  gastric  irritation  or  gastric  insufficiency,  such, 
for  example,  as  an  affection  of  the  appetite,  the  occurrence  of  thirst  or 
xerostomia,  the  occurrence  of  reflex  pain  or  of  pain  in  the  epigastrium,, 
palpitation,  cough  and  dyspnoea,  tingling  and  numbness,  impaired  vision, 
buzzing  in  the  ears,  drowsiness,  sleeplessness,  nightmare,  vertigo  or 
hiccough,  inability  to  do  mental  work,  and  the  dread  of  a  fatal  seizure,, 
cardiac  or  apoplectic.  Similar  symptoms  are  present  in  cases  of  nervous 
dyspepsia ;  but  their  characteristic  in  this  condition  is  their  great  ex- 
aggeration. 

Practically,  the  cases  may  be  divided  into  two  classes — first,  cases  of 
gastric  irritation,  with  prominence  of  one  or  more  nervous  symptoms  ;  and 
second,  cases  in  which  the  digestion  is  normal  as  regards  the  chemical 
processes,  but  there  are  nervous  symptoms,  either  general  or  related  to  the 
stomach. 

With  regard  to  the  cases  in  which  there  is  exaggeration  of  the  reflex 
nervous  symptoms  which  occur  in  cases  of  gastric  irritation,  nothing  need 
further  be  said.  But  a  few  remarks  are  necessary  on  the  exaggeration  of 
the  symptoms  referable  to  the  stomach,  which  occur  in  neuroses  of  the 
organ.  The  first  is  pain.  Such  cases  are  frequently  referred  to  as 
gastralgia.  In  this  condition  pain  may  be  extremely  severe,  neuralgic  or 
shooting  in  character,  rarely  dull  and  heavy,  and  showing  a  tendency  to 
disappear  suddenly.  In  some  cases  pain  occurs  chiefly  before  food  is  taken, 
food  relieving  it ;  in  others,  and  this  is  more  important  from  a  diagnostic 
point  of  view,  the  pain,  although  more  or  less  present  between  meals,  is 
exaggerated  after  a  meal,  is  localised  in  the  epigastrium,  and  is  accom- 
panied by  acute  and  localised  tenderness.  This  localisation  is  sometimes 
remarkably  limited.  It  may  persist  in  the  same  situation  during  the 
whole  course  of  the  illness,  a  condition  which  renders  the  diagnosis  from 
ulcer,  in  some  cases,  extremely  difficult.  The  absence  of  vomiting  with 
this  localised  pain  is  very  distinctive  of  neuroses.  It  is  a  noticeable  fact 
in  these  cases,  also,  that  the  local  pain  and  tenderness  is  not  so  greatly 
affected  by  the  character  of  the  food,  whether  solid  or  liquid,  as  in  cases  of 
ulcer  of  the  stomach.  Frequently  also  there  are  associated  abdominal 
neuralgic  pains,  sometimes  referred  to  the  colon,  and  sometimes  to  the 
small  intestine. 

Eructatio  nervosa  is  a  condition  which  frequently  occurs  in  nervous 
dyspepsia,  and  is  the  persistent  and  repeated  eructation  of  gas  or  of  small 
quantities  of  liquid  from  the  stomach.     The  eructated  liquids  may  show 


DISEASES  OF  THE  STOMACH.  663 

that  the  process  of  digestion  is  normal ;  the  liquid  may  also  be  neutral  or 
even  alkaline,  and  in  some  cases  it  is  no  doubt  swallowed  saliva.  The  con- 
dition is  dependent  on  irritability  of  the  stomach,  which  causes  slight  eructa- 
tions. Associated  with  this  condition,  but  more  frequently  existing  by  itself, 
is  the  excessive  flatulence  from  which  those  patients  suffer;  a  flatulence 
which  may  be  described  as  enormous,  coming  on  at  irregular  intervals,  and 
frequently  suddenly;  occurring  also  towards  the  end  of  the  day,  and 
rendering  the  patient  utterly  unable  to  perform  any  exertion,  mental  or 
bodily.  The  origin  of  the  gas  in  this  condition  is  partly  swallowed  air  and 
partly,  it  is  supposed,  transudation  from  the  blood.  The  disappearance  of 
the  flatulence  may  be  as  sudden  as  its  onset. 

Hiccough  is  a  prominent  symptom  in  individual  cases,  and  is  usually 
associated  with  the  presence  of  irritating  food  in  the  stomach.  Its  onset 
and  disappearance  may  both  be  quite  sudden. 

Vomitus  nervosa  is  a  symptom  commonly  observed  in  women.  It 
usually  occurs  after  meals,  is  associated  with  well-marked  constipation, 
and  frequently  with  very  few  symptoms  of  indigestion  of  food.  The 
vomiting  is  sudden,  and  consists  almost  solely  of  the  normal  contents  of 
the  stomach,  and  may  persist  with  slight  periods  of  intermission  for  years. 

Nervous  dyspepsia  occurs  chiefly  in  young  adults,  and  in  females  above 
the  age  of  puberty,  and  is  characterised  by  the  symptoms  previously 
mentioned,  by  a  variable  appetite,  and  by  the  fact  that  the  chemical  pro- 
cesses of  digestion  are  found  to  be  practically  normal.  There  may  be  a 
moderate  dilatation  of  the  organ  at  one  time  or  other  in  the  course  of  the 
illness. 

The  course  is  usually  a  very  characteristic  one ;  inasmuch  as  a  patient 
suffering  severely  from  gastralgia  or  flatulence  for  a  period,  say  of  a  month, 
will  have  a  complete  and  sudden  intermission  of  the  symptoms.  Such  a 
patient  feels  during  the  attack  unfit  for  any  occupation ;  during  the  inter- 
mission he  may  feel  perfectly  well.  Such  an  occurrence  as  this  in  the 
course  of  a  case  indicates  clearly  its  nervous  origin. 

Such  an  abrupt  intermission  does  not  occur  in  those  cases  of  nervous 
dyspepsia  which  present  the  peculiarity  of  being  able  to  take  bub  little 
food,  even  the  simplest  diet ;  even  milk  causes  discomfort,  solid  food  being 
absolutely  intolerable.  These  patients  may  remain  in  this  condition  for 
months,  may  waste  considerably,  and  be  unfit  to  follow  any  occupation. 
In  these  cases  the  stomach  appears  simply  to  have  struck  work,  there 
being  no  sign  of  any  organic  disease  of  the  mucous  membrane.  As  a  rule 
it  is  an  intractable  condition,  though  some  patients  may  improve  consider- 
ably under  treatment.  Improvement,  to  some  extent,  is  the  rule  in 
cases  of  nervous  dyspepsia ;  relapses,  however,  are  extremely  common. 
Although  temporary  relief  can  be  given,  no  permanent  cure  is  made  in 
severe  cases. 

Diagnosis. — The  question  of  the  diagnosis  of  functional  from  organic 
disease  of  the  stomach  frequently  arises  in  individual  cases,  and  may 
present  great  difficulty  for  a  time.  This  is  more  especially  the  case  in  the 
diagnosis  of  neuroses  of  the  stomach  from  ulcer  of  that  organ,  in  the 
diagnosis  of  gastric  catarrh  from  nervous  dyspepsia  and  gastric  insufficiency, 
and  in  that  of  cancer  from  gastric  insufficiency.  Some  of  the  points  in  the 
diagnosis  will  be  considered  under  the  headings  of  Catarrh,  Ulcer,  and 
Cancer. 

Ulcer. — Cases  both  of  gastric  irritation  and  of  nervous  dyspepsia 
may,  with  difficulty,  be   distinguished  from  ulcer,  and   there  are  not  a 


664  ALIMENTARY  SYSTEM. 

few  cases  of  ulcer  of  the  stomach  which  present  the  features  of  gastric 
irritation,  and  only  declare  themselves  as  ulcer  after  some  time  by  an 
attack  of  haeniateniesis.  In  the  diagnosis  between  gastric  irritation 
and  ulcer  the  points  to  be  looked  to  are  the  character  of  the  pain  and 
of  the  vomiting,  and  the  course  of  the  disease.  Both  may  occur  in  young 
women ;  in  ulcer  the  pain  is  localised  in  the  epigastrium,  and  is  associated 
with  localised  tenderness,  both  pain  and  tenderness  being  dependent  on 
the  ingestion  of  food,  and  relieved  by  vomiting.  Vomiting  is  frequent, 
especially  in  the  continued  taking  of  unsuitable  diet,  and  repeated  vomiting 
may  lead  to  some  amount  of  wasting.  Hsematemesis  may  or  may  not  be 
present. 

Gastric  irritation,  on  the  other  hand,  presents  during  its  course  quite 
different  features.  Although  there  may  be  times  at  which  nausea  and 
vomiting  occur  after  food,  for  a  duration  of,  perhaps,  two  or  three  months, 
yet  the  vomiting  is  not  a  serious  or  frequent  symptom,  and  is  very  readily 
controlled  by  treatment.  Indeed,  it  ceases  without  any  definite  medical 
treatment,  because  such  patients  find,  unlike  those  suffering  from  ulcer, 
that  certain  foods  can  be  taken  with  least  distress,  and  so  gradually  confine 
themselves  to  a  more  or  less  suitable  diet.  Vomiting  is  more  frequent  in 
women  than  in  men  in  gastric  irritation.  The  pain  in  gastric  irritation  is 
not  continuously  epigastric,  nor  is  it  associated  with  localised  tenderness. 
When  epigastric  pain  is  present  it  is  usually  transient,  being  produced  by 
some  definite  indiscretion  in  diet.  Epigastric  pain  in  gastric  irritation, 
however,  may  go  through  to  the  back,  as  in  ulcer  ;  and  if  frequent  vomit- 
ing is  present,  there  may  be  a  diffused  tenderness  over  the  stomach ;  but 
all  these  symptoms  may  be  rapidly  relieved  within  the  course  of  a  week  by 
appropriate  treatment,  much  more  rapidly  than  in  cases  of  ulcer. 

Nervous  dyspepsia  gives  rise  to  more  difficulty  in  the  diagnosis.  It  is 
a  disease,  like  ulcer,  most  common  in  young  women  over  the  age  of 
puberty.  One  of  the  main  distinctions  of  cases  of  nervous  dyspepsia  from 
those  of  ulcer  lies  in  the  fact  that  they  present  extremely  variable  and 
changing  symptoms.  There  are  cases  of  what  may  be  called  localised 
gastralgia,  both  in  men  and  women,  which  are  frequently  diagnosed  as 
ulcer.  In  these  there  is  pain  after  food,  often  excruciating,  and  localised  to 
one  spot  in  the  epigastrium ;  and  the  only  point  in  which  such  pain  and 
tenderness  differs  from  that  which  occurs  in  ulcer  is,  that  it  is  shooting  and 
very  severe.  Thus,  as  regards  the  local  tenderness,  a  slight  pressure  on 
the  tender  spot  may  call  forth  agonies  of  pain,  an  occurrence  which  is 
sometimes  observed  in  cases  of  ulcer;  and  this  localised  tenderness  in 
nervous  dyspepsia  may  last  for  years,  unless  appropriate  treatment  is 
adopted.  In  most  cases  it  differs  widely  from  the  similar  pain  in  ulcer  by 
the  absence  of  vomiting.  Other  cases  of  nervous  dyspepsia  which  simulate 
ulcer  are  those  in  which  there  is  repeated  vomiting,  which  may  occur  after 
every  meal  in  the  day,  is  usually  associated  with  epigastric  pain,  and  may 
continue  for  many  months.  It  is  correctly  described  as  vomitus  nervosa, 
and  is  associated  with  other  manifestations  of  an  excitable  nervous  system, 
such  as  referred  pains,  headache,  neuralgia,  and  dysmenorrhcea. 

Broadly  speaking,  one  looks  for  the  distinction  between  nervous 
dyspepsia  and  ulcer  in  the  fact  (l)that  in  nervous  dyspepsia  the  symptoms 
frequently  cease  suddenly  for  a  week  or  so,  without  any  obvious  change 
being  made  in  the  diet  or  treatment ;  and  (2)  that  if  such  patients  are 
placed  under  strict  dieting  for  about  a  fortnight,  they  do  not  improve  so 
decidedly  or  so  readily  as  those  suffering  from  ulcer. 


DISEASES  OF  THE  STOMACH.  665 

Gastric  catarrh. — The  symptoms  of  chronic  gastric  irritation  and 
of  chronic  catarrh  bear  a  close  superficial  resemblance,  but  they  are 
essentially  two  different  diseases,  since  one  is  purely  functional  and  the 
other  is  a  chronic  inflammatory  process.  Gastric  irritation  may, 
of  course,  pass  into  catarrh,  and  continued  irritation  leads  to  chronic 
inflammation ;  but  there  are  many  cases  in  which  this  is  not  so.  Both 
are  essentially  chronic  affections,  with  a  tendency  to  have  more  or 
less  acute  exacerbations.  Epigastric  pain,  which  is  only  a  transient 
symptom  in  gastric  irritation,  is  frequent,  and  often  severe,  in  chronic 
gastric  catarrh.  It  is  commonly  diffuse,  and  associated  with  one  or  more 
areas  of  epigastric  tenderness,  varying  in  size.  Vomiting  is  present  in 
both  affections,  and  in  catarrh  is  more  closely  associated  with  diffuse 
epigastric  pain  than  in  gastric  irritation.  The  vomited  matters  in  gastric 
irritation  are  usually  hyperacid,  and  consist  of  the  digesting  food,  with  no 
mucus.  In  chronic  catarrh,  on  the  other  hand,  the  vomiting  is  never 
hyperacid,  the  food  is  but  slightly  digested,  and  there  is  an  excess  of  mucus 
present.  Moreover,  in  catarrh  there  is  a  greater  dilatation  of  the  stomach 
than  in  chronic  gastric  irritation.  In  gastric  catarrh,  hamatemesis, 
although  not  common,  may  occur,  and  is  always  slight ;  in  gastric  irritation 
it  does  not  occur  at  all. 

In  some  of  these  cases,  the  employment  of  a  test  meal  is  of  great  service 
in  the  diagnosis  of  the  condition.  It  is  not  uncommon  for  cases  of  nervous 
dyspepsia  to  be  diagnosed  as  catarrh,  and  indeed  catarrh  or  gastritis  is 
frequently  diagnosed  in  cases  which  are  purely  functional.  This  is  an 
important  point,  inasmuch  as  catarrh  of  the  stomach  is  a  very  serious 
disease ;  while  functional  disorder  is  comparatively  unimportant,  or,  at 
any  rate,  it  is  an  affection  which  is  readily  amenable  to  treatment.  The 
attacks  of  epigastric  pain  and  vomiting,  occasionally  with  a  little  mucus, 
which  occur  in  some  cases  of  nervous  dyspepsia,  may  lead  to  the  suspicion 
of  catarrh  of  the  organ ;  but  if  the  case  is  watched,  it  is  found  that  these 
symptoms  soon  subside  when  a  suitable  diet  is  ordered,  and  that  the 
presence  of  mucus  is  not  constant.  Moreover,  and  this  is  the  chief  point, 
the  amount  of  free  hydrochloric  acid  which  is  present  in  the  digesting 
gastric  contents  is  not  only  not  below,  but  is  more  frequently  above,  normal 
— 0'3  grm.  per  cent,  or  over. 

Functional  gastric  insufficiency  cannot  be  mistaken  for  catarrh,  inas- 
much as  the  history  shows  some  definite  cause,  whether  acute  disease  or 
not,  for  the  affection  of  the  stomach ;  and  there  is  an  absence  of  epigastric 
pain  and  of  vomiting,  with  usually  a  large  aniomit  of  flatulence  and  a 
moderate  degree  of  dilatation  of  the  organ,  these  symptoms  being  greatly 
relieved  by  treatment.  In  cases,  however,  of  atrophy  of  the  glands  of  the 
organ,  by  no  means  common,  the  condition  is,  as  a  rule,  secondary  to 
catarrh,  and  presents  many  features  of  what  has  been  called  "  permanent 
gastric  insufficiency."  There  is,  however,  in  many  of  these  cases  epigastric 
pain  ;  vomiting  is  not  common,  although  nausea  may  be  present.  Flatulence 
is  a  feature,  and  wasting  is  frequently  observed. 

Cancer. — The  diagnosis  of  cancer  from  functional  disease  is  more 
appropriately  considered  under  the  heading  devoted  to  it.  It  may,  however, 
here  be  said  that  in  the  early  stages  of  cancer  of  the  stomach  there  are 
indefinite  symptoms  of  indigestion  of  food  occurring  in  the  course  of  the 
day ;  there  may  be  no  specific  symptoms  pointing  to  cancer.  The  points, 
however,  which  are  to  be  attended  to  are  the  continuance  of  the  symptoms 
during  a  definite  period,  and  without  any  history  of  a  definite  cause,  asso- 


666  ALIMENTARY  SYSTEM. 

ciated  with  a  progressive  wasting  and  loss  of  appetite,  and,  it  may  be, 
cachexia. 

Treatment. — The  treatment  of  functional  disorders  of  the  stomach  is 
both  medicinal  and  dietetic,  as  well  as  hygienic.  Massage,  electricity,  and 
washing  out  of  the  stomach  are  also  of  benefit  in  some  cases.  Without 
dietetic  treatment  drugs  are  of  little  avail,  although  these  are  essential, 
especially  in  the  treatment  of  the  disorders  in  their  aggravated  form.  The 
conditions  which  have  to  be  treated  in  functional  disorders  are — (1)  altera- 
tions in  the  secretions  of  gastric  juice,  either  hyperacidity,  due  to  hydro- 
chloric acid,  or  deficient  acidity,  due  to  the  diminution  in  the  secretion 
of  the  hydrochloric  acid — sometimes  there  is  a  diminution  in  the  amount 
of  pepsin ;  (2)  alterations  in  the  motor  activity  of  the  stomach,  chiefly  a 
diminished  motor  activity  (myasthenia  or  atony  of  the  organ),  or  occasion- 
ally irritability  or  spasmodic  contraction ;  (3)  a  varying  degree  of  hyper- 
excitability  of  the  nerves,  accompanied  in  many  cases,  no  doubt,  by  a 
persistence  of  the  digestive  congestion  of  the  organ,  these  conditions  being 
shown  by  discomfort  and  pain. 

The  restoration  of  the  functions  of  the  organ,  when  disordered,  is  a 
matter  of  time  and  treatment,  and  frequently  symptoms  have  to-be  treated 
immediately,  such  as  pain,  vomiting,  flatulence,  and  excessive  acidity.  The 
remedies  which  are  used  in  treatment  act  as  antacids,  as  stimulants  of 
secretion,  as  stimulants  to  the  motor  activity,  as  sedatives,  both  for  the 
increased  secretion  of  gastric  juice  and  for  nervous  and  motor  irritability ; 
and  in  some  cases  remedies  supply  an  insufficiency  in  the  secretion  of 
hydrochloric  acid  or  pepsin.  It  cannot  be  too  strongly  laid  down  that 
anything  like  powerful  remedies  in  the  treatment  of  functional  disorder  of 
the  stomach  is  out  of  place,  and  does  more  harm  than  good. 

In  the  dietetic  treatment  of  functional  disorder,  the  objects  to  be  borne 
in  mind  are  (1)  to  give  the  patient  during  the  day  only  as  much  food 
as  the  stomach  can  digest  with  the  least  discomfort;  (2)  to  remove 
irritants  from  the  diet.  With  all  these  conditions,  there  is  delay  of  food 
in  the  organ,  and  in  some  cases  the  stomach  contents  are  always  acid, 
irritating  the  organ ;  in  others,  digestion  seems  to  cease  with  the  stoppage 
of  the  secretion  of  gastric  juice.  In  all  cases  the  amount  of  food  taken  in 
health  is  to  be  reduced  in  quantity,  and  altered  in  character,  either  because 
of  the  pain  produced,  or  of  vomiting,  or  of  irritability  of  the  organ.  The 
irritating  substances  in  the  diet  which  do  harm  in  the  disordered  stomach 
are  too  large  a  quantity  of  organic  acids  or  salts,  such  as  exists  in  beef, 
beef -tea,  many  vegetable  foods,  and  fruits ;  an  excessive  amount  of  carbo- 
hydrates, more  particularly  starch,  and  all  fats ;  and,  lastly,  a  large  amount 
of  cellulose.  All  food  accessories  are  irritants,  or  tend  to  become  irritants, 
in  gastric  disorder;  and  indeed  some,  such  as  tea  and  alcoholic  drinks,  are  in 
many  cases  the  chief  factors  in  producing  gastric  irritation.  In  the  treat- 
ment of  all  aggravated  forms  of  functional  disorder,  food  accessories  have 
to  be  removed  from  the  dietary — all  alcoholic  drinks,  strong  tea,  and 
strong  coffee  more  particularly. 

Of  great  importance  in  the  treatment  of  functional  disorder  is  the' 
regulation  of  the  mode  of  life,  more  particularly  for  the  prevention  of 
the  recurrence  of  attacks  than  for  the  immediate  treatment  of  subacute 
attacks.  Eegular  and  digestible  meals,  regular  hours,  and  regular  pleasur- 
able exercise  are  the  three  chief  factors  in  the  treatment  of  such  patients 
between  then1  attacks.  Not  more  than  three  meals  are  to  be  taken  in  the 
day,  with,  as  a  rule,  nothing  between  them.     The  largest  meal  is  to  be  in 


DISEASES  OF  THE  STOMACH.  667 

the  middle  of  the  day,  and  after  each  meal  there  ought  to  be  a  period  of  half 
an  hour  at  least  for  rest  and  recreation.  In  many  cases,  too,  attention  to 
the  teeth  is  of  the  highest  importance,  inasmuch  as  the  disordered  digestion 
may  depend  to  a  very  great  extent  on  deficiency  of  the  teeth,  or  other 
conditions  preventing  proper  mastication. 

Gastric  irritation. — Cases  of  gastric  irritation  come  under  treatment 
at  various  stages  of  the  disease ;  usually,  however,  in  one  of  the  subacute 
attacks,  and  with  a  history  of  recurrent  attacks  for  perhaps  years  past. 
Many  of  these  patients  find  that  particular  articles  of  diet  disagree  with 
them,  and  gradually  omit  them,  so  that  they  improve  for  a  time,  relapsing 
again  when  they  commit  dietetic  indiscretions. 

The  first  class  of  cases  to  be  considered  are  those  in  which  there  is 
great  discomfort  after  food,  with  referred  pains  in  the  chest,  with  irregular 
vomiting  of  a  very  acid  fluid,  and  with  flatulence.  Such  patients  have 
hypersecretion  of  hydrochloric  acid,  as  well  as  hyperesthesia  of  the 
organ.  They  have  to  be  treated  medicinally  by  means  of  alkalies  and 
sedatives.  The  alkalies  to  be  used  are: — Bicarbonate  of  sodium,  10  to  20 
grs. ;  prepared  chalk,  5  to  10  grs. ;  magnesium  carbonate,  5  to  10  grs. 
Trousseau's  antacid  powder,  which  is  an  excellent  preparation,  consists 
of — bicarbonate  of  sodium,  5  grs. ;  prepared  chalk,  10  grs. ;  magnesium 
carbonate,  5  grs.  One  powder  is  to  be  taken  after  each  principal  meal, 
and  before  going  to  bed.  Alkalies  may  be  administered,  either  before 
or  after  meals.  Administered  before  meals  in  hyperacidity  of  the  gastric 
contents,  they  neutralise  the  acidity  of  the  liquid,  thus  preparing  the 
stomach  for  the  next  meal ;  and,  by  means  of  the  carbonic  acid  which  is 
developed,  they  aid  the  organ  in  expelling  its  contents.  Alkalies  are 
given  after  meals,  if  the  period  of  discomfort  in  digestion  usually  occurs 
one  to  two  hours  after  a  meal.  They  ought  then  to  be  given  just  before 
the  patient  becomes  uncomfortable,  and  are  useful  this  way  in  neutralising 
hyperacidity. 

Alkalies  are  very  useful,  combined  with  sedatives.  Mild  sedatives  which 
may  be  used  in  gastric  disorder,  are  bromide  of  potassium  (5-  to  10-gr.  doses) 
and  iodide  of  potassium  (2-gr.  doses).  The  three  most  useful,  however,  are 
cocaine  hydrochlorate,  in  doses  of  from  one-fifth  to  one-tenth  of  a  grain ; 
dilute  hydrocyanic  acid,  in  doses  of  3  minims ;  liquor  morphin£e  hydro- 
chloratis,  in  doses  of  5  to  10  minims.  Carbolic  acid  in  5-  to  10-minim  doses 
of  the  glycerinum,  ether  and  chloroform  in  the  form  of  spiritus,  and  bismuth 
in  the  form  of  carbonate,  are  all  mild  sedatives ;  bismuth  also  acting  some- 
what as  an  antacid. 

In  the  actual  treatment,  it  is  usually  best  to  begin  with  an  alkaline 
mixture,  containing  15  gr.  of  bicarbonate  of  sodium,  3  minims  of  dilute 
hydrocyanic  acid,  5  minims  of  spirits  of  ether,  and  an  ounce  of  infusion  of 
gentian,  to  be  taken  before  the  mid-day  and  evening  meal,  and  again  on 
going  to  bed.  If  there  is  much  discomfort,  morphine  may  be  added  to  this 
mixture.  It  has  the  disadvantage,  however,  of  increasing  the  constipation. 
The  same  mixture  may  be  given  after  meals,  and  in  the  conditions  which 
have  been  already  mentioned.  This  mixture  is  extremely  serviceable  for 
warding  off  the  attacks  of  indigestion,  to  which  the  patient  is  liable  for 
many  months  after  the  acute  attack  has  been  treated.  It  may  be  taken 
for  a  long  time  without  doing  any  harm.  Antispasmodic  remedies  may 
have  to  be  given,  of  which  the  most  serviceable  are  spirits  of  ether  and  sal 
volatile,  in  doses  of  15  to  30  minims,  or  cajeput  oil  in  doses  of  1  to  3 
minims.    Hot  water,  not  more  than  a  wine-glassful,  frequently  acts  very  well 


668  ALIMENTARY  SYSTEM. 

as  an  antispasmodic.  In  such  cases  the  administration  of  pepsin  and  other 
digestive  ferments  is  of  no  avail,  since  there  is  no  diminution  of  pepsin  in 
the  gastric  juice.  The  exhibition  of  acids  before  meals  is  often  useful,  as 
they  have  a  tendency  towards  diminishing  the  hypersecretion  of  acids. 
The  administration  of  acids  sometimes  does  harm,  and  many  patients 
show  great  intolerance  in  respect  of  them.  The  antiseptic  remedies  so 
frequently  given  are  of  little  use,  there  being  no  bacterial  fermentation  to 
counteract.  The  diet  has  to  be  carefully  regulated,  first,  by  cutting  off  all 
alcoholic  drinks,  and  strong  tea  and  coffee;  by  disallowing  green  vegetables, 
fruit,  and  frequently  potatoes;  and  allowing  only  white  bread,  or  toast 
made  from  white  bread. 

If  the  symptoms  are  severe,  the  patient  had  better  be  placed  on  a 
sterilised  milk  diet,  at  any  rate  for  a  few  days ;  and  then  a  graduated  diet 
may  be  begun  by  means  of  bread  and  milk,  Benger's  food  and  milk,  or  the 
white  of  an  egg  beaten  up  with  milk.  This  diet  must  be  adhered  to  for 
breakfast  and  for  the  evening  meal ;  the  mid-day  meal  consisting  of  boiled 
fish  or  chicken,  or  a  grilled  minced  chop  may  be  added,  with  a  milk  pudding 
or  custard.  All  prepared  foods,  pastry,  and  jam  are  to  be  avoided.  When 
the  functions  of  the  stomach  are  recovering,  butter  may  be  added  to  the 
dietary,  and  vegetables  slowly,  namely,  spinach  and  green  peas.  In  these 
cases  any  danger  from  the  loss  of  vegetable  food  may  be  obviated,  by  giving 
the  juice  of  half  an  orange  or  half  a  lemon  in  water  twice  a  day  with 
meals. 

In  long-continued  gastric  irritation,  besides  the  symptoms  which  have 
been  mentioned,  patients  may  show  at  the  commencement  of  treatment 
wasting,  flabbiness  of  the  muscles,  and  frequently  increased  myotatic 
irritability.  Usually  in  these  cases  there  is  some  dilatation  of  the  organ, 
it  may  be  only  after  the  principal  meal  of  the  day.  Besides  careful  dieting, 
which  has  been  already  discussed,  it  may  be  said  that  the  administration 
of  sedatives,  such  as  morphine,  for  any  length  of  time,  has  to  be  carefully 
watched,  as  the  atony  of  the  organ  may  be  thereby  increased. 

A  very  useful  method  of  treatment  for  such  patients  is  to  insist  upon 
complete  rest  from  work  of  all  kinds,  and  active  exercise ;  and  to  combine 
with  this  rest,  massage  of  the  abdomen,  as  well  as  of  the  body  generally. 
Abdominal  massage  is  to  be  chiefly  over  the  stomach  region,  and  to  be 
practised  from  left  to  right,  in  the  direction  in  which  the  contents  of  the 
organ  are  expelled.  Constipation  and  diarrhoea  have  to  be  treated ;  the 
latter  condition,  unless  lienteric,  being  usually  caused  by  the  constipation. 
The  treatment  of  the  lienteric  diarrhoea  in  gastric  irritation  is  that  of 
the  stomach  disorder  itself,  i.e.  dietetic,  with  the  administration  of 
alkalies  and  sedatives  before  meals.  Constipation  itself,  which  is  often  a 
troublesome  symptom  in  these  cases,  is  to  be  treated  by  an  evening  pill  of 
aloes  and  belladonna,  with,  if  necessary,  an  aperient  saline  in  the  morning, 
or  a  small  injection. 

Gastric  insufficiency. — The  treatment  of  gastric  insufficiency  has 
to  be  carried  out  on  different  lines  to  those  of  gastric  irritation;  inas- 
much as  not  only  is  there  a  deficiency  in  the  functions  of  the  stomach, 
but  the  general  nutrition  is  affected,  sometimes  profoundly  so,  as  shown 
by  wasting,  general  weakness,  and  anaemia.  The  general  treatment  is 
therefore  of  great  importance — hygienic  treatment,  and  the  adminis- 
tration of  tonics.  The  tonics  which  are  most  useful  are  quinine  and 
iron;  but  these  must  be  given  in  very  small  doses,  not  more  than  1 
to  2  grs.  of  sulphate  of  iron,  and  1  to  2  grs.  of  sulphate  of  quinine.    Other 


DISEASES  OF  THE  STOMACH.  669 

treatment,  which  is  useful  in  these  conditions,  is  general  massage.  Ab- 
dominal massage  is  also  of  service  in  the  treatment  of  the  atony  of  the 
stomach,  which  is  usually  present.  The  treatment  of  the  stomach  condition 
itself  is  different  from  that  of  gastric  irritation,  inasmuch  as  acids  are  here 
of  great  service.  Acids  are  usually  administered  in  the  form  of  dilute  nitro- 
hydrochloric  acid,  in  doses  of  7  to  15  minims,  with  tincture  of  nux  vomica, 
4  to  6  minims ;  or  liquor  strychnine,  3  to  5  minims.  Bitters  have  to  be 
given  with  care  in  this  condition,  inasmuch  as  they  are  apt  to  irritate  the 
organ.  They  are  best  withheld,  a  simple  flavouring  agent  being  added  to 
the  mixture.  In  some  cases  the  use  of  pepsin  in  powder  is  beneficial, 
in  doses  of  5  to  10  grs.  after  meals,  or  it  may  be  mixed  with  the  acid 
mixture.  Antispasmodics  may  be  required  for  the  flatulence.  In  gastric 
insufficiency  it  is  not  always  advisable  to  completely  withhold  stimulants, 
and  it  is  frequently  of  service  to  administer  with  meals  twice  a  day  two 
teaspoonfuls  of  brandy,  with  3  minims  of  liquor  strychnine  in  an  ounce  of 
water. 

Nervous  dyspepsia. — This  is  a  matter  of  extreme  difficulty.  Not 
only  do  individual  cases  present  an  infinite  variety  of  aspect,  but 
in  most  instances  the  effect  of  treatment  is  but  slightly  noticeable 
at  first. 

The  dietetic  treatment  has  to  be  regulated  to  suit  the  needs  of  individual 
cases.  In  those  cases  where  vomiting  is  severe,  or  where  there  is  much 
pain  in  the  epigastrium,  patients  may  require  to  be  placed  on  a  strict  milk 
diet,  at  any  rate  for  a  time ;  and  in  some  cases  the  withholding  of  all  food 
by  the  mouth,  and  the  adoption  of  rectal  feeding,  has  a  most  beneficial  effect. 
Patients  with  nervous  dyspepsia  frequently  exhibit  remarkable  idiosyn- 
crasies as  regards  diet,  and  the  routine  adoption  of  a  milk  diet  in  all  cases 
is  not  to  be  recommended.  The  physician,  therefore,  has  to  feel  his  way 
in  the  dieting,  in  order  to  determine  what  articles  of  diet,  whether  solid. 
or  liquid,  are  most  easily  digested  by  the  patient.  In  cases  where  vomit- 
ing is  not  a  marked  feature,  and  where — associated  with  epigastric  distress 
— there  is  a  large  amount  of  flatulence  and  numerous  referred  pains,  the 
dieting  has  to  be  conducted  on  the  same  lines,  and  mistakes  are  often  made 
in  keeping  such  patients  exclusively  on  a  milk  diet.  Frequently,  too,  such 
patients  are  taught  to  wash  their  stomachs  out  themselves,  which  they  do 
at  irregular  intervals,  without  medical  direction.  This  practice  is  one 
strongly  to  be  condemned  in  nervous  dyspepsia,  inasmuch  as  washing  out 
the  stomach  ought  rarely  to  be  resorted  to,  and  then  only  to  relieve  great 
distress. 

The  medicinal  treatment  of  nervous  dyspepsia  varies  considerably, 
inasmuch  as  such  patients  show  an  idiosyncrasy  towards  drugs,  similar  to 
that  they  exhibit  towards  articles  of  food ;  some  are  intolerant  of  acids, 
others  of  alkalies,  others  of  iron,  others  of  quinine  and  of  bitters.  A 
particular  case  would  alter,  in  this  respect,  while  under  treatment.  Great 
care,  therefore,  is  to  be  taken  in  the  administration  of  drugs  to  these 
patients,  in  order  not  to  further  increase  the  mischief.  They  nearly  all 
require  a  stomachic  sedative  in  one  of  the  forms  previously  discussed  under 
Gastric  Irritation.      They  do  not  require  antiseptic  remedies. 

As  regards  the  administration  of  acids  or  alkalies,  the  decision  as  to 
which  should  be  used  must  be  made  from  the  facts  previously  mentioned, 
as  regards  the  presence  or  absence  of  hyperacidity  during  digestion.  In 
some  cases,  the  ordinary  digestive  mixtures  do  more  harm  than  good,  and 
all  that  is  required  is  a  quinine  and  iron  tonic,  to  be  given  after  meals.     If 


670  ALIMENTARY  SYSTEM. 

the  patients  do  not  improve  under  this  treatment,  if  they  still  have  a  large 
amount  of  distress  and  pain,  if  the  flatulence  is  great,  and  if  there  is  well- 
marked  insomnia  and  wasting  and  flabbiness  of  the  muscles,  the  only  plan 
of  treatment  which  is  of  service  is  complete  rest  in  bed,  with  isolation 
and  graduated  diet,  with  employment  of  general  massage  and  local  massage 
of  the  abdomen.  Eest  and  treatment  generally  should  be  continued  for  at 
least  a  month.  Some  of  these  patients  completely  recover,  whilst  with 
others  relapses  are  extremely  frequent ;  and  these  are  brought  on,  not  only 
by  indiscretions  in  diet,  but  also  by  worry  and  unhealthy  occupation. 


GASTEITIS. 

Gastritis  is  either  acute  or  chronic,  and  is  an  inflammation  of  the 
mucous  membrane  of  the  stomach.  Acute  gastritis  may  be  divided 
into  three  different  classes — (1)  simple,  gastritis  catarrhalis;  (2)  toxic, 
gastritis  toxica,  due  to  poisons ;  (3)  infective,  gastritis  mycotica,  due 
to  bacterial  infection.  Chronic  gastritis  is  usually  called  chronic  gastric 
catarrh,  and  may  occur  as  a  sequel  to  the  acute  stage ;  it  may,  however, 
be  chronic  from  the  first. 

Acute  Cataeehal  Gasteitis. 

Etiology. — Gastric  catarrh,  or  inflammation  of  the  mucous  mem- 
brane, is  the  result  of  irritation  of  the  organ.  The  irritants  which  act  in 
the  production  of  catarrh  are  certain  articles  of  diet,  such  as  those  which 
contain  a  large  excess  of  cellulose,  and  especially  food  accessories,  such  as 
alcohol  and  tea.  Teetotallers,  however,  are  not  exempt  from  the  disease. 
A  second  factor  in  producing  the  disease  is  persistent  hyperacidity  of  the 
gastric  contents,  such  as  is  present  in  cases  of  gastric  irritation,  or  is 
due  to  an  excessive  amount  of  organic  acids  and  salts  taken  with  the  food, 
or  to  an  excessive  formation  of  organic  acids  (lactic,  butyric,  and  acetic)  by 
the  bacterial  fermentation  of  carbohydrates  in  the  stomach.  The  delay  of 
food  in  the  stomach  is  a  third  factor  which  aids  in  the  production  of 
catarrh. 

Although  these  conditions  must  be  considered  the  direct  inciting  causes 
of  inflammation — and  in  some  cases  they  are  the  only  factors — yet  gastric 
catarrh  is  closely  associated  in  its  etiology,  not  only  with  other  diseases  of 
the  stomach,  but  with  certain  general  diseases.  It  has  previously  been 
stated  that  it  may  follow  gastric  irritation.  It  is  sometimes  associated 
with  cancer  of  the  organ ;  it  is  but  rarely  associated  with  ulcer,  at  any  rate 
in  the  early  stages  of  the  ulceration. 

As  regards  general  diseases,  it  is  predisposed  to  by  such  acute  febrile 
diseases  as  tuberculosis,  scarlet  fever,  measles,  rickets,  pysemia  and  septic 
diseases,  pneumonia,  and  typhoid  fever.  Although  acute  catarrh  of  the 
stomach  may  occur  in  the  course  of  these  diseases,  it  is  usually  in  the 
convalescent  stage  that  it  is  likely  to  arise ;  during  this  period,  when  the 
stomach  is  recovering  from  the  diminution  of  function  which  occurs  during 
the  acute  illness,  dietetic  indiscretions  are  the  exciting  cause,  and  may  lead 
to  inflammation.  In  chronic  Bright's  disease,  catarrh  of  the  stomach  may 
be  observed ;  in  gout  it  may  be  present,  although  a  functional  disturbance 
is  the  more  common. 

Pathology. — In   acute   catarrh    there  is   active   congestion   of   the 


DISEASES  OF  THE  STOMACH.  671 

mucous  membrane,  with  transudation  of  liquid,  and  a  large  amount  of 
interstitial  infiltration  of  the  tissues  by  leucocytes.  The  epithelial  cells 
lining  the  membrane  show  an  increase  in  the  number  of  goblet  cells  which 
produce  mucus.  The  cells  also  undergo  proliferation,  and  are  eventually 
cast  off,  to  a  greater  or  less  extent,  in  the  mucus  and  liquid  which  is 
exuded  from  the  surface. 

The  most  important  change,  however,  which  occurs  in  catarrh  of  the 
gastric  mucous  membrane  affects  the  glands.  The  epithelium  of  these 
becomes  swollen  and  granular,  the  nucleus  being  pushed  to  the  side  of  the 
cell ;  the  cell  stains  badly,  the  granules  are  not  soluble  in  ether,  but  are 
soluble  in  dilute  acids.  This  affection  of  the  glands,  which  occurs  in  catarrh 
of  other  mucous  membranes,  such  as  those  of  the  nose  and  of  the  bronchi,  is  of 
great  importance  in  the  stomach,  inasmuch  as  the  secretion  of  the  glands  is 
of  prime  importance  in  digestion.  Besides  the  granular  change  in  the  cells, 
they  may  also  undergo  mucinoid  degeneration,  which  has  the  same  effect 
as  the  granular  degeneration,  namely  destroying  their  function.  Fatty 
degeneration  of  the  cell  may  also  be  the  final  stage  of  a  catarrhal 
condition.  Granular  and  fatty  degeneration  are  more  common  than  the 
mucinoid,  the  fatty  change  being  well  marked  in  chronic  catarrh  of  the 
organ.  When  the  catarrh  becomes  chronic,  the  secretion  of  mucus  is 
continuous,  at  any  rate  for  some  time,  although,  if  a  large  area  of  the 
epithelium  is  destroyed,  the  secretion  diminishes.  The  degeneration  of  the 
glands  is  well  marked,  and  is  referred  to  as  parenchymatous  degeneration. 
Associated  with  this  degeneration,  or  in  some  cases  constituting  the  chief 
change  in  the  mucous  membrane,  is  interstitial  fibrosis.  Pigmentation  may 
also  occur.  In  the  majority  of  cases  the  morbid  changes  are  limited  to  the 
mucous  membrane  (see  "  Cirrhosis  of  the  Stomach,"  p.  685). 

Catarrh  affects  chiefly,  or  at  any  rate  primarily,  the  pyloric  region  of 
the  stomach  ;  but  in  not  a  few  cases  it  involves  the  whole  of  the  mucous 
membrane,  and  the  degeneration  of  the  glands  may  be  more  marked  in  the 
cardiac  region  than  in  the  pyloric.  It  is  rare  in  chronic  catarrh  to  find  the 
whole  of  the  mucous  membrane  affected  by  the  change,  although  in  the 
subacute  cases,  which  occur  in  the  course  of  tuberculosis  and  other  febrile 
diseases,  the  change  may  be  practically  universal  over  the  mucous  mem- 
brane. The  muscular  coat  is  sometimes  affected.  There  may  be  simple 
atrophy  of  the  muscular  cell,  but  both  fatty  and  colloid  degeneration  have 
been  described. 

The  condition  of  ttat  mamdloiU  is  one  of  fibrosis  of  the  pyloric  region, 
associated  with  atrophy  of  the  mucous  membrane ;  the  mucous  membrane 
forming  small  projections  or  polypi.  Microscopically,  there  is  a  small- 
celled  infiltration,  with  the  formation  of  connective  tissue  between  the 
gland  elements.  In  this  condition,  by  the  constriction  of  the  mouth  of 
the  gland,  cysts  are  formed,  usually  not  large  in  size,  but  frequently 
quite  visible  to  the  naked  eye.  In  one  case  of  chronic  catarrh,  in 
which  there  was  mucinoid  degeneration,  Langerhans  found  the  mucous 
membrane  formed  into  a  sort  of  sponge  by  the  numerous  cysts  which 
had  developed. 

The  pathological  condition  which  is  present  in  gastric  catarrh  is  that, 
during  normal  digestion,  there  is  great  interference  with  the  necessary 
blood  supply ;  secondly,  that  there  is  a  great  diminution  in  the  amount  of 
hydrochloric  acid  secreted,  to  a  less  extent  in  the  amount  of  pepsin.  In 
acute  cases  hydrochloric  acid  and  pepsin  may  be  completely  absent  for  a 
time.     There  is  in  the  subacute  and  acute  cases  motor  irritability  of  the 


672  ALIMENTARY  SYSTEM. 

organ,  and  in  more  chronic  cases  there  is  a  diminution  of  motor  activity, 
and  commonly  dilatation.  Absorptive  processes  are  also  greatly  interfered 
with.  The  process  of  digestion  is  therefore  greatly  modified.  In  acute 
catarrh  there  is  practically  no  digestion  in  the  stomach ;  in  mild  chronic 
catarrh  there  is  inability  to  digest  an  ordinary  mixed  meal,  owing  to 
the  diminished  function.  Although  some  gastric  juice  is  secreted  in 
these  cases,  yet  it  is  not  sufficient  to  complete  the  digestion,  and  the 
organ  is  too  weak  to  expel  its  contents.  Delay  of  food  therefore  occurs, 
and  this  may  be  so  marked,  that  ultimately  bacterial  fermentation  ensues, 
leading  to  hyperacidity  due  to  organic  acids,  and  thus  to  a  continued 
irritation  of  the  organ. 

Symptoms. — Acute  catarrh  is  usually  sudden  in  its  onset,  and  is 
associated  with  either  a  food  or  a  drink  debauch.  Frequently,  in 
these  cases,  there  is  a  predisposition  to  disordered  digestion.  The  onset 
is  characterised  by  vomiting  and  great  epigastric  pain.  There  is  some- 
times a  slight  rise  of  temperature,  which  is  of  but  short  duration.  There 
is  great  prostration.  The  face  is  pale,  sometimes  drawn  and  sunken; 
the  skin  is  cold  and  clammy,  and  may  be  covered  with  sweat.  The 
pulse  is  frequent,  regular,  compressible.  There  are  diffuse  pains  in  the 
back  and  limbs;  giddiness  on  exertion  is  sometimes  a  marked  symptom. 
Delirium  is  not  common.  There  is  complete  loss  of  appetite,  accompanied 
by  thirst  and  dryness  of  the  mouth.  Herpes  labialis  is  not  infrequent. 
The  symptoms,  therefore,  of  acute  catarrh  are  those  which  are  observed 
when  an  acute  irritant  poison  is  taken  into  the  stomach,  and,  indeed,  acute 
catarrh  is  caused  by  an  irritant.  The  pain  is  burning,  passes  through  to 
the  back,  and  is  accompanied  by  a  sense  of  oppression  on  the  chest.  The 
epigastric  pain  is  associated  with  deep  tenderness,  and  frequently  with 
rigidity  of  the  muscles  over  the  stomach  region.  Vomiting  is  a  well- 
marked  symptom,  the  vomited  matters  consisting  at  first  of  partly  digested 
food,  later  on  of  food  which  shows  no  sign  of  digestion.  The  liquids 
removed  from  the  stomach  or  vomited  are  slightly  acid,  neutral,  and  even 
alkaline.  There  is  no  free  hydrochloric  acid  present.  In  the  later  stages 
organic  acids  may  be  present,  due  to  bacterial  fermentation;  and  an 
examination  of  the  stomach  contents  frequently  reveals  the  presence  of 
bacteria  in  the  mucus,  even  when  no  fermentation  occurs.  Slimy  mucus 
may  be  present  in  the  vomit,  and  streaks  of  blood  and  bile  may  be  found. 
The  urine  is  scanty  and  high-coloured,  and  deposits  lithates. 

Acute  catarrh  runs  a  fairly  rapid  course,  and  frequently  becomes 
chronic.  It  is  probably  never  a  primary  disease,  unless  some  powerful 
irritant,  either  a  poison  or  a  poisonous  food,  is  taken,  or  unless  it  arises  in 
the  course  of  an  acute  febrile  disorder,  such  as  typhoid  fever,  pneumonia, 
rheumatic  fever,  and  scarlet  fever. 

Catarrh  is  sometimes  subacute.  It  is  characterised  by  the  same 
symptoms,  which,  however,  are  not  so  severe  as  in  the  acute  form.  The 
epigastric  pain  and  vomiting  come  on  after  food.  Flatulence  and  nausea, 
with  anorexia,  are  well-marked  symptoms ;  and,  during  the  course  of  the 
illness,  the  patient  himself  gradually  reduces  his  food  to  a  minimum. 
Dilatation  of  the  stomach  is  a  feature  of  subacute  catarrh,  and  palpation 
of  the  stomach  may  give  rise  to  painful  peristalsis  of  the  organ.  The 
complexion  is  pale  and  sallow,  and  there  is  well-marked  wasting.  The 
bowels  are  constipated,  and  large  quantities  of  mucus  may  be  passed  in 
the  stools.  The  stomach  contents  show  the  characteristics  as  those  of 
acute  catarrh. 


DISEASES  OF  THE  STOMACH.  673 

Diagnosis. — This  will  be  considered  more  fully  under  the  heading  of 
"  Chronic  Catarrh."  Here  it  may  be  said  that  the  diagnosis  of  acute  and 
subacute  catarrh  rest  on  the  following  points : — (1)  The  relation  of  great 
and  diffuse  epigastric  pain  and  vomiting  to  the  ingestion  of  food ;  (2)  the 
presence  of  mucus  in  the  stomach  and  in  the  stools ;  (3)  the  absence  of 
pepsin  and  hydrochloric  acid  in  the  stomach  contents ;  (4)  the  dilatation 
and  condition  of  irritability  of  the  organ. 

Prognosis. — Both  acute  and  subacute  catarrh  may  be  recovered 
from,  if  they  are  treated  correctly.  The  duration  of  subacute  catarrh  is 
variable,  and  it  may  be  months  before  the  patient  can  resume  an  ordinary 
diet,  and  even  then  great  care  has  to  be  exercised  in  the  choice  of  food. 

Treatment. — In  both  acute  and  subacute  catarrh  the  main  object  of 
treatment  is  to  give  the  stomach  rest.  It  is  usually  advisable  to  commence 
the  treatment  by  washing  out  the  organ  once  or  twice,  preferably  with  a 
dilute  alkaline  solution  (1  per  1000  of  sodium  hydrate).  This  removes  the 
irritants  from  the  organ,  and  frequently  stops  the  vomiting.  For  the  first 
twenty -four  or  thirty-six  hours,  or  even  longer,  according  to  the  condition  of 
the  patient,  rectal  feeding  is  to  be  adopted,  by  the  administration  of  nutrient 
enemata  every  four  hours.  The  enemata  may  consist  of  2  oz.  of  milk  with 
an  egg  beaten  up  in  it,  of  beef -tea,  and  two  teaspoonfuls  of  liquor  pan- 
creaticus,  with  20  or  30  grs.  of  bicarbonate  of  sodium.  This  mixture  must 
be  injected  warm,  not  hot,  into  the  rectum.  Peptonised  gruel  may  be 
substituted  for  the  beef -tea  in  the  injection,  and  if  the  enemata  cause 
irritation,  the  use  of  a  little  cocaine  ointment  is  beneficial.  Peptone 
suppositories,  containing  60  per  cent,  of  peptone,  may  occasionally  be 
substituted  for  the  enemata.  Thirst  may  be  relieved  by  a  limited  allow- 
ance of  ice,  or  by  the  use  of  effervescing  lozenges.  If  the  retching  still 
continues,  a  hypodermic  injection  of  morphine  may  be  given ;  and  hot 
belladonna  fomentations  to  the  epigastrium  frequently  give  great  relief. 

Feeding  by  the  mouth  must  be  commenced  gradually,  and  with  great 
care,  small  quantities  of  sterilised  milk  being  tried  every  few  hours  at 
the  commencement;  the  amount  of  milk  being  very  gradually  increased 
when  it  is  found  that  it  causes  irritation  or  vomiting.  When  the  more 
acute  symptoms  have  subsided,  medicinal  treatment  is  of  inuch  value,  and 
the  best  remedies  are  dilute  hydrochloric  or  nitro-hydrochloric  acid,  in  10- 
to  15-minim  doses,  combined  with  3  minims  of  hydrocyanic  acid,  or  10  minims 
of  liquor  morphinse  hydrochloratis.  The  later  treatment  is  one  of  careful 
diet  and  of  general  tonics. 

Chronic  Cataeehal  Gasteitis. 

Chronic  gastric  irritation  is  frequently  diagnosed  as  chronic  catarrh; 
an  important  mistake,  since  gastric  irritation  is  highly  amenable  to  treat- 
ment, and  chronic  catarrh  very  refractory,  being  an  inflammation  of  the 
mucous  membrane  associated  with  organic  changes.  Gastric  irritation, 
however,  frequently  leads  to  chronic  catarrh  of  the  organ,  the  early  stages 
of  the  latter  being  thus  associated  with  hyperacidity.  These  are  the  cases 
which  have  been  called  "acid"  catarrh.  Chronic  catarrh,  on  the  other 
hand,  frequently  follows  acute  or  subacute  catarrh,  developed  in  the  course 
of  a  febrile  illness.  It  is  a  serious  affection,  characterised  clinically  by  a 
chronic  afebrile  course,  with  subacute  exacerbations ;  by  epigastric  pain 
and  diffuse  tenderness ;  by  the  vomiting  of  mucus  and  of  a  liquid  greatly 
deficient  in  hydrochloric  acid. 
vol.  1.— 43 


674  ALIMENTARY  SYSTEM. 

Symptoms. — When  insidious  in  origin,  its  early  symptoms  are  those 
characteristic  of  gastric  irritation;  when  established,  the  symptoms  are 
mainly  referable  directly  to  the  stomach  and  the  stomach  region,  and  are 
dependent  on  the  ingestion  of  food,  and  on  the  delay  of  undigested  food  in 
the  organ. 

The  epigastric  pain  begins  directly  after  the  ingestion  of  food,  and  lasts 
for  an  hour  or  two  hours,  or  more.  It  is  sometimes  severe,  and  is  only 
relieved  by  vomiting.  So  severe  is  the  pain  in  some  instances,  that  the 
patient  excites  vomiting  to  get  rid  of  the  stomach  contents,  and  may  half 
starve  himself  in  fear  of  its  onset.  In  milder  cases,  the  onset  of  epigastric 
pain  may  be  delayed  some  time  after  the  ingestion  of  food.  The  pain  is 
diffuse,  burning  in  character,  and  may  go  through  to  the  back.  Epigastric 
tenderness  is  usually  present  in  the  course  of  all  cases  of  chronic  catarrh ; 
it  is  diffuse  and  not  excessive,  and  usually  there  are  areas  more  tender 
than  others.  These  tender  areas  have  been  considered  to  represent  erosions 
of  the  mucous  membrane.  Epigastric  tenderness  disappears  very  soon  under 
proper  treatment,  much  sooner  than  the  similar  tenderness  in  ulcer  of  the 
stomach.  When  first  seen,  both  epigastric  pain  and  tenderness  may  be 
absent,  owing  to  the  patient  having  been  compelled  to  take  a  diminished 
diet. 

Nausea  is  frequent,  even  when  vomiting  is  absent,  and  may  come  on 
during  a  meal,  and  so  prevent  the  patient  taking  any  more  food.  Vomiting 
is  never  absent  at  one  or  other  time  in  the  course  of  chronic  catarrh,  and  in 
the  history  there  are  periods  in  which  vomiting  is  severe ;  these  are  the 
periods  of  subacute  attacks.  Vomiting  is  usually  in  relation  to  food,  but 
may  occur  in  the  morning.  The  vomited  matters  generally  contain  an 
excess  of  unpigmented  mucus,  and  a  deficient  amount  of  hydrochloric  acid. 
The  mucus  may  be  very  abundant ;  it  may  be  in  strings,  or  flocculent  and 
sticky.  In  the  first  class  of  cases  it  is  frequently  passed  in  the  motions,  as 
in  subacute  catarrh.  In  long-continued  catarrh,  there  is  a  history  of  the 
vomiting  of  mucus,  but  at  the  time  of  seeing  the  patient  the  mucus  may 
be  absent  from  the  vomit.  Microscopically,  the  vomit  shows  strings  of 
mucus,  and  a  few  leucocytes  and  goblet  cells,  more  or  less  degenerated. 
Bacteria  may  be  present,  and  a  few  red  corpuscles  may  be  seen.  The 
mucus  must  be  distinguished  from  the  swallowed  mucus  coming  from  the 
bronchial  tubes  and  lungs.  This  is  pigmented  and  contains  a  large  number 
of  pus  cells.  The  vomit  may  be  slightly  acid,  neutral,  or  faintly  alkaline. 
When  there  is  bacterial  fermentation,  the  vomit  is  highly  acid,  due  to  the 
presence  of  organic  acids.  There  is  also  great  deficiency  of  free  hydro- 
chloric acid.  Pepsin  is  present  in  the  mild  cases,  even  when  the  hydro- 
chloric acid  is  greatly  diminished.  According  to  Boas,  pepsinogen  may  be 
present  instead  of  pepsin.  The  vomited  food  is  thus  very  imperfectly 
digested. 

In  gastric  catarrh,  profuse  hsematemesis  does  not  occur.  Blood  may, 
however,  occur  in  streaks  in  the  vomit,  or  as  much  as  2  or  3  oz.  may  be 
brought  up.  Haematemesis,  however,  does  not  tend  to  recur,  and  is  usually 
a  sign  of  an  erosion  of  the  mucous  membrane  being  present. 

Flatulence  is  a  frequent  symptom  in  chronic  catarrh,  but  not  so 
marked  as  in  gastric  insufficiency  and  in  nervous  dyspepsia,  unless  there 
is  bacterial  fermentation  of  the  food  in  the  dilated  stomach.  Dilatation 
is  frequently  present,  and  presents  the  signs  and  symptoms  discussed  on 
p.  679. 

In  chronic  catarrh  the  face  is  frequently  pale  and  sallow ;  it  has  an 


DISEASES  OF  THE  STOMACH.  675 

earth}7  complexion,  and  tends  to  become  somewhat  anxious-looking  in  cases 
of  long  standing.  The  appetite  is  usually  diminished  except  in  the  early 
stages,  and  later  there  may  be  complete  anorexia.  Thirst  may  be  present, 
especially  when  the  stomach  is  dilated  ;  the  tongue  is  coated  with  a  thick 
whitish  yellow  fur;  the  breath  is  often  offensive.  In  some  cases  the 
tongue  is  broad  and  flabby.  In  many  instances,  especially  in  young  adults, 
there  is  an  enlargement  and  reddening  of  the  fungiform  papillae.  The 
bowels  are  usually  constipated,  and  mucus  may  be  present  in  the  stools ; 
diarrhoea  is  only  occasionally  observed.  The  urine,  in  aggravated  catarrh, 
is  passed  in  small  amount,  is  not  infrequently  neutral  or  alkaline,  and 
contains  an  excess  of  phosphates.  There  may  be  a  continued  diminution 
of  the  secretion  of  chlorides,  as  in  other  stomach  conditions. 

In  most  cases  of  chronic  catarrh  there  is  wasting,  which  may  be  con- 
tinuous if  the  disease  is  neglected.  With  suitable  treatment,  however,  the 
patient  soon  begins  to  regain  weight.  The  loss  of  weight  is  increased  by 
repeated  vomiting,  and  especially  when  there  is  associated  catarrh  of  the 
small  intestine,  or  when  catarrh  is  associated  with  a  serious  disease,  such 
as  pulmonary  tuberculosis  and  chronic  Bright's  disease.  Eeflex  nervous 
symptoms  are  also  frequently  present. 

Diagnosis. — The  diagnosis  from  chronic  gastric  irritation  has  already 
been  discussed  (p.  663).  It  now  remains  only  to  mention  shortly  its 
distinction  from  other  diseases  of  the  stomach,  in  which  there  is  epigastric 
pain  and  vomiting.  In  ulcer,  for  example,  there  is  pain  directly  after  the 
ingestion  of  food,  with  vomiting,  as  in  catarrh ;  but  the  difference  lies  in 
the  fact  that  in  ulcer  the  pain  as  well  as  the  tenderness  is  usually 
localised,  whereas  in  catarrh  it  is  more  diffuse,  and  the  areas  of  tender- 
ness are  not  so  localised.  Vomiting  is  frequent  in  both ;  but  the  characters 
of  the  vomited  matters  in  ulcer  show  those  of  ordinary  digesting  food  in 
the  organ,  or,  it  may  be,  hyperacidity,  due  to  excess  of  hydrochloric  acid ; 
whereas  in  gastric  catarrh  there  is  an  excess  of  mucus  and  a  diminution 
in  the  amount  of  hydrochloric  acid.  Hxematemesis  may  be  profuse  in 
ulcer ;  in  chronic  catarrh  it  is  not  common,  and  when  present  only  slight 
in  extent.  It  must  be  remembered,  however,  that  catarrh  may  be 
associated  with  chronic  Bright's  disease,  with  mitral  stenosis  or  with 
cirrhosis  of  the  liver,  in  all  of  which  diseases  profuse  hsematemesis  may 
occur  independent  of  catarrh. 

In  cancer,  epigastric  pain  is  more  irregular  than  in  either  ulcer  or 
catarrh ;  it  is  frequently  lancinating  in  character,  and  may  be  associated 
with  the  presence  of  a  tumour  and  a  greatly  dilated  stomach.  The  other 
symptoms  of  cancer  are  also  present. 

Many  cases  of  gastric  irritation,  when  first  seen,  cannot  be  diagnosed 
except  by  means  of  a  test  meal.  By  these  means  the  question  of  the 
diminution  of  hydrochloric  acid  and  of  the  degree  of  the  digestive  power 
of  the  stomach  can  be  tested.  Not  infrequently,  too,  it  is  found  in  catarrh 
that  the  stomach  washings  contain  mucus  whereas  no  mucus  was  present 
in  the  vomit. 

Prognosis. — If  the  case  comes  under  treatment  in  a  subacute 
attack,  and  the  history  of  previous  illness  has  not  been  a  long  one,  a 
favourable  prognosis  may  be  given,  if  the  patient  be  a  young  adult ;  for  in 
these  cases,  by  proper  treatment,  the  catarrh  diminishes  and  may  com- 
pletely heal,  leaving  but  little  or  no  damage  in  the  gastric  mucous 
membrane. 

If,  however,  as  not   infrequently  happens,   the   patient  continues   to 


676  ALIMENTARY  SYSTEM. 

commit  dietetic  indiscretions,  the  symptoms  recur,  and  the  disease  becomes 
aggravated,  inflicting  permanent  injury  on  the  stomach,  even  if  some 
amelioration  of  the  patient's  condition  may  be  obtained.  In  middle-aged 
and  old  people,  chronic  gastric  catarrh  is  a  serious  affection,  being  much 
less  amenable  to  treatment,  and  frequently  ending  in  permanent  damage  to 
the  digestion.  When  associated  with  tuberculosis  or  chronic  Bright's 
disease,  a  permanent  cure  is  :not  to  be  expected,  though  the  disease  may  be 
partly  held  in  check  by  appropriate  treatment.  Gastric  catarrh  may  end 
in  atrophy  of  the  mucous  membrane. 

Treatment. — In  the  treatment  of  chronic  catarrh  the  same  general 
regulations  as  regards  mode  of  life  and  general  hygienic  treatment  are 
necessary  as  in  chronic  gastric  irritation  (p.  666  et  seq.).  Eest  is  essential, 
a  rest  both  bodily  and  mental,  and  rest  of  the  stomach  by  means  of 
diminution  of  food  and  the  administration  of  sedatives.  It  is  frequently 
advisable  to  commence  treatment  by  washing  out  the  stomach,  not  only 
because  it  gives  relief  to  the  patient,  but  also  because  an  examination  of 
the  stomach  washings  is  an  aid  to  the  diagnosis  of  the  condition  of  the 
stomach.  In  washing  out  the  stomach  it  is  best  to  use  an  alkaline  solu- 
tion, such  as  a  solution  of  bicarbonate  of  sodium  (3  to  6  drms.  to  the  pint). 

As  regards  medicinal  treatment,  acids  are  here  of  great  value, — 
dilute  nitro-hydrochloric  and  dilute  hydrochloric  acid,  in  doses  of  10  to 
15  mimims  after  food.  They  are  usefully  combined,  in  some  cases,  with 
dilute  hydrocyanic  acid  or  liquor  morphinse  hydrochloratis,  if  there  is  much 
pain  in  the  epigastrium.  In  other  cases  they  have  to  be  combined  with 
pepsin  as  an  aid  to  the  digestive  process.  Constipation  may  be  relieved 
in  the  manner  previously  indicated. 

The  diet  in  the  treatment  of  chronic  catarrh  is  of  the  greatest  import- 
ance. Such  patients  cannot  take  much  food,  inasmuch  as  the  stomach  is 
incapable  of  coping  with  it.  In  the  initial  treatment  a  liquid  diet  is  to  be 
adopted.  In  the  severer  cases,  peptonised  milk  solely  ;  in  the  less  severe 
cases,  sterilised  milk  or  skimmed  milk  may  be  used,  diluted,  if  necessary, 
with  water  that  has  been  boiled.  It  is  advisable  to  add  some  salt  to  the 
milk,  which  must  be  administered  regularly  every  two  hours  of  the  day  and 
night.  A  patient  on  this  diet  must  rest,  and  it  may  be  some  time  before 
a  change  of  diet  is  permissible.  The  first  change  that  takes  place  being  the 
addition  to  the  milk,  once  or  twice  a  day,  of  some  one  or  other  of  the  com- 
mercial partly  digested  foods,  such  as  Benger's.  If  this  agrees,  crumb  of 
white  bread  may  be  gradually  substituted  for  it,  and  toast  may  be  eaten. 
The  first  addition  of  the  solid  food  is  to  be  pounded  boiled  fish  or  minced 
chicken  ;  and  the  white  of  an  egg  may  now  be  given  with  milk.  Change 
to  a  more  solid  diet  than  this  must  be  very  gradual,  every  additional  article 
of  diet  being  at  once  removed  if  it  causes  distress.  During  this  period, 
both  local  and  general  massage  are  of  great  service ;  but,  as  a  rule,  it  may 
be  said  that  massage  of  the  stomach  region  ought  not  to  be  performed  in 
chronic  gastric  catarrh,  inasmuch  as  it  irritates  the  organ.  In  some  cases 
the  administration  of  small  doses  of  alkalies,  such  as  10  grs.  of  bicarbonate 
of  sodium  before  food,  is  beneficial  when  the  patient  is  recovering,  tending 
to  stimulate  the  secretion  of  the  gastric  juice.  Bitters,  as  a  rule,  aggravate 
the  condition,  and  there  may  be  well-marked  intolerance  of  them.  Tonics 
may  have  to  be  given,  but  only  in  small  doses. 


DISEASES  OF  THE  STOMACH.  677 

Acute  Toxic  Gasteitis. 

Toxic  gastritis  is  the  inflammation  of  the  stomach  produced  by 
the  swallowing  of  corrosive  or  irritant  poisons.  Infective  gastritis 
(gastritis  mycotica)  results  from  the  invasion  of  the  stomach  by  pathogenic 
bacteria. 

Etiology. — The  poisons  which  produce  toxic  gastritis  are — (1)  sul- 
phuric, hydrochloric,  and  nitric  acids ;  (2)  caustic  alkalis,  such  as  potash  ; 
(3)  oxalic  acid,  carbolic  acid,  and  nitrobenzol ;  (4)  arsenious  acid,  corrosive 
sublimate,  potassium  cyanide,  chlorate  of  potassium,  phosphorus.  Phos- 
phorus has  not  usually  a  direct  corrosive  action  on  the  mucous  membrane, 
but  it  produces  a  well-marked  fatty  degeneration  of  the  glands  as  well  as 
of  the  muscular  coat.  The  other  poisons  act  as  corrosives  or  great  irritants, 
producing  here  and  there  in  the  stomach  destruction  of  the  mucous  mem- 
brane and  intense  inflammation,  which  is  shown  by  swelling  and  reddening, 
and  by  the  extravasation  of  blood.  The  results  of  this  action,  if  the  patient 
lives,  are — (1)  That  in  the  parts  most  affected  by  the  poison  ulcers  are 
formed,  sometimes  at  the  cardiac  orifice,  sometimes  in  the  mid-region  of 
the  stomach,  and  sometimes  near  the  pylorus.  These  ulcers  run  the  course 
of  the  chronic  ulcer  of  the  stomach.  (2)  In  the  parts  less  affected  by  the 
poison,  chronic  inflammation  is  set  up,  as  shown  by  the  excessive  secretion 
of  the  mucus.  There  is,  however,  subsequently  fibrosis  of  the  mucous 
membrane,  with  the  degeneration  of  the  glands.  Cysts  may  be  found, 
as  well  as  the  condition  called  ttat  mamelloni. 

Symptoms. — The  symptoms  are  those  of  acute  gastritis,  the  pain 
being  great,  the  vomiting  frequent,  and  the  epigastric  tenderness  severe. 
The  appetite  is  lost,  and  intense  thirst  is  frequently  present.  Collapse  is 
common,  with  a  cold,  clammy  skin  and  a  rapid  pulse.  Giddiness  is 
frequent  after  the  first  effects  of  the  poison  have  passed  off.  Albuminuria 
and  hasmaturia  are  not  uncommon.  The  vomited  matters  consist  of  the 
ordinary  contents  of  the  stomach,  with  mucus,  stained  with  more  or  less 
altered  blood,  and  by  the  poison  itself.  It  may  thus  be  either  strongly 
acid  or  strongly  alkaline  or  neutral.  Blood  in  the  vomit  may  be  due  to 
poisoning  by  mineral  acids,  or  caustic  alkalies,  arsenic,  corrosive  sublimate, 
and  phosphorus.  With  caustic  alkalies  the  blood  is  brown  or  black,  and  is 
diffused  through  a  very  tenacious  mucus.  When  the  patient  does  not  die 
from  the  immediate  effects  of  the  poison,  the  subsequent  history  of  the 
case  is  either  one  of  subacute  or  chronic  gastric  catarrh  ;  or  of  permanent 
gastric  insufficiency,  due  to  destruction  of  the  mucous  membrane ;  or,  it 
may  be,  of  chronic  ulcer. 

Diagnosis. — For  the  special  diagnosis,  works  on  toxicology  must  be 
consulted.  All  that  it  is  necessary  to  say  here  is,  that  in  the  diagnosis  of 
acute  gastritis  due  to  poison,  the  suddenness  of  the  onset  of  the  symptoms 
without  previous  illness,  their  severity,  and  the  character  of  the  vomited 
matters,  as  a  rule,  render  the  diagnosis  simple ;  as  well  as  the  fact  that 
there  is  a  clear  history  of  all  the  symptoms  appearing  suddenly  after  the 
patient  has  drunk  some  liquid  or  eaten  some  food. 

Poisoning  by  foods  frequently  gives  rise  to  very  severe  gastric  symptoms, 
like  those  of  toxic  gastritis.  In  this  case  the  history  is  of  symptoms 
coming  on  directly  after  partaking  of  a  particular  meal,  and  also  of  the  fact 
that  other  members  of  the  same  family  are  affected  by  the  same  disease. 
The  symptoms  are  gastro-intestinal,  and  consist  in  vomiting  and  diarrhoea, 
pains,  and  great  prostration  ;  subsequently,  fever  may  be  developed.     Death 


678  ALIMENTARY  SYSTEM. 

may  occur  in  coma.  Food  poisoning  arises  from  pork  in  its  various  forms, 
but  sometimes  from  other  kinds  of  meats,  sometimes  from  tinned  salmon 
and  sardines. 

Infective  Gasteitis. 

Etiology. — The  stomach  is  sometimes  the  seat  of  specific  lesions  of 
certain  infective  disorders.  In  diphtheria,  in  rare  instances,  the  mucous 
membrane  may  be  covered  by  a  false  membrane.  In  smallpox,  an 
eruption  may  be  present;  and  tuberculosis,  typhoid,  and  syphilitic 
ulcers  of  the  mucous  membrane  are  amongst  the  rarities  of  post-mortem 
examinations.  The  term  phlegmonous  gastritis  is  applied  to  cases  where 
either  a  single  abscess  is  formed  in  the  stomach  wall,  or  where  there  is 
diffuse  inflammation  of  the  submucosa,  due  to  bacterial  invasion,  ending 
in  the  formation  of  multiple  foci  of  suppuration.  A  single  large  abscess 
of  the  stomach  is  not  common,  and  is  diagnosed  by  the  discharge  of  pus 
in  the  vomit.  Multiple  suppuration  may  lead  to  numerous  ulcers  of  the 
mucous  membrane,  and  is  usually  associated  with  peritonitis.  Other  cases 
of  bacterial  infection  of  the  stomach  have  been  described.  Frankel 
described  a  case  of  diffuse  inflammation  of  the  submucosa,  associated  with 
effusion  of  blood  and  the  formation  of  bladders  of  gas.  This  occurred  in  a 
man  who  had  sustained  a  compound  fracture  of  the  right  index-finger. 
The  symptoms  were  those  of  acute  gastritis  with  jaundice,  death  occurring 
two  and  a  half  days  after  the  onset  of  the  symptoms.  Klebs  described  two 
cases,  under  the  heading  of  "  gastritis  bacillaris " ;  and  in  anthrax  the 
'stomach  may  be  infected  by  micro-organisms. 

Most  of  the  cases  of  infective  gastritis  are  secondary  to  a  general 
infection  of  the  body.  Deininger  has  published  a  case  which  was 
apparently  primary — a  case  of  diffuse  suppuration  occurring  in  a  drunkard, 
with  well-marked  cirrhosis  of  the  liver.  The  majority  of  cases  of  infective 
gastritis  are  chiefly  of  pathological  interest.  Eecovery  may  take  place,  and 
scars  be  left  in  the  position  of  the  abscesses  (Diettrich). 


ATEOPHY  AND   DEGENEKATIONS. 

The  degeneration  of  the  glands  of  the  stomach  occurs,  as  has  been  seen, 
as  the  result  of  inflammation.  It  may  be  non-inflammatory.  Degenera- 
tions maybe  divided  into  three  classes — (1)  primary  atrophy;  (2)  fatty 
degeneration  of  the  glands,  occurring  in  cancer  of  the  stomach  or  of  other 
parts  of  the  body,  and  in  some  cases  of  long-standing  ulcer ;  (3)  albuminoid 
degeneration. 

Primary  atrophy  of  the  stomach  is  not  very  common,  and  occurs 
usually  in  persons  beyond  middle  age,  from  50  to  75  years  of  age.  Cases, 
however,  have  been  described  by  Eosenheim,  Schirren,  and  others,  occurring 
between  the  ages  of  19  and  36.  It  is  possible  that  in  some  of  these  cases 
the  origin  of  the  atrophy  was  inflammatory. 

In  atrophy  of  the  stomach,  the  walls  are  greatly  thinned,  so  as  to  be 
almost  semi-transparent.  The  arrangement  of  the  mucous  membrane  in 
rugae  is  lost ;  the  organ  is  dilated,  and  there  is  no  post-mortem  digestion 
of  the  mucous  membrane,  showing  that  the  secretory  glands  are  deficient  in 
activity.  -  Microscopically,  the  glands  are  atrophied  in  many  parts,  being 
absent  in  others  and  their  place  occupied  by  granules.  In  pernicious 
anaemia,  atrophy  of  the  stomach  may  occur.    (2)  Fatty  degeneration  occurs 


DISEASES  OF  THE  STOMACH.  679 

in  cases  of  cancer  of  the  pylorus,  and  of  cancer  elsewhere.  It  is  part  of  the 
effect  of  the  cancerous  growth  on  the  body,  and  is  similar  to  the  fatty 
degeneration  of  the  heart  muscle,  of  the  liver,  and  of  the  kidney  cortex, 
which  constantly  occurs  in  such  conditions.  In  long-standing  ulcer  of  the 
stomach,  a  similar  degeneration  may  occur.  (3)  Albuminoid  degeneration 
occurs  in  long-standing  cases  of  pulmonary  tuberculosis,  in  syphilis,  and  in 
prolonged  suppuration.  In  the  mucous  membrane  the  vessels  are  affected, 
as  well  as  the  muscle  fibres  between  the  glands  and  the  connective  tissue. 


CIEEHOSIS. 

Cirrhosis  ventriculi  (plastic  linitis,  Brinton)  has  been  described  as  a 
chronic  inflammation  of  the  walls  of  the  stomach,  associated  with  hyper- 
trophy of  the  muscular  coat,  usually  involving  the  whole  of  the  organ  and 
producing  contraction.  I  am  myself  not  at  all  certain  that  such  a  disease 
really  exists.  The  specimens  which  I  have  myself  seen,  illustrating  this 
condition,  have  all  proved,  on  microscopical  examination,  to  be  cases  of 
diffuse  cancer  of  the  stomach  (see  "  Cancer,"  p.  697). 

Cirrhosis  of  the  mucous  membrane  of  the  organ  may  occur  as  the  result 
of  catarrh,  but  in  the  disease  called  cirrhosis  ventriculi  the  whole  wall  of 
the  stomach  is  affected  by  fibroid  change,  and  the  capacity  of  the  organ 
greatly  reduced,  so  that  it  holds  as  little  as  four  ounces  in  some  cases. 
In  post-mortem  examinations  one  does  meet  with  cases  of  malignant  disease 
in  the  upper  part  of  the  abdomen,  in  which  the  stomach  becomes  fibroid  as 
well  as  cancerous  from  without ;  and,  in  still  rarer  cases,  this  fibrosis  of  the 
stomach  is  the  sequel  of  chronic  peritonitis.  But  as  to  the  existence  of  a 
primary  disease  such  as  cirrhosis  ventriculi,  the  evidence  is  scanty  or 
wanting. 

HAEMORRHAGE. 

Etiology. — In  hsematemesis  and  melsena  the  blood  may  come  from 
the  stomach,  and  in  profuse  hasmatemesis  there  is  usually  melyena.  The 
blood  which  is  vomited  may  come  from  various  sources.  It  may  be 
swallowed,  or  it  may  come  from  the  stomach  itself.  (1)  It  may  be 
swallowed  in  fracture  of  the  base  of  the  skull,  in  epistaxis,  and  in  bleeding 
from  the  lungs  or  oesophagus;  (2)  it  may  come  from  the  stomach  itself, 
and  may  be  due  to  some  lesion  in  the  stomach,  some  tumour  or  growth 
attached  to  the  organ,  or  to  some  general  disease  of  the  body.  In  these 
cases  bleeding  may  be  either  capillary,  or  due  to  the  opening  of  the  large 
vessel,  vein  or  artery. 

Bleeding  may  occur  in  venous  or  mechanical  congestion,  which  affects 
chiefly  the  pyloric  region  of  the  organ,  and  is  primarily  due  to  dilatation  of 
the  right  side  of  the  heart,  such  as  occurs  chiefly  in  mitral  disease  of  long 
standing,  especially  mitral  stenosis.  Venous  congestion  also  occurs  in  the 
obstruction  of  the  portal  circulation,  whether  acute,  as  in  portal 
thrombosis,  or  chronic,  as  in  cirrhosis  of  the  liver.  In  gastritis  there  is, 
as  a  rule,  slight  haematemesis,  whether  it  be  due  to  the  direct  action  of  a 
poison,  or  to  catarrh. 

Ulcer  of  the  stomach  is  the  commonest  cause  of  hsematemesis,  and  is 
frequently  clue  to  the  opening  of  a  large  vessel.  Cancer  also  leads  to 
hsematemesis.     The  hsematemesis  of  excessive  vomiting  is,  as  a  rule,  very 


680  ALIMENTARY  SYSTEM. 

slight.  In  abdominal  aneurysm  there  may  be  a  rupture  through  the 
stomach  wall,  causing  death  by  haematemesis.  A  malignant  growth  in  a 
neighbouring  part  may  invade  the  stomach,  ulcerating  and  leading  to  the 
same  result. 

The  general  diseases  which  lead  to  haematemesis  are  as  follows : — Acute 
febrile  diseases,  such  as  tropical  malarial  fevers,  typhus  fever,  and  the 
hasmorrhagic  forms  of  variola,  scarlet  fever,  measles,  and  diphtheria ;  the 
various  forms  of  septic  fever  and  pyaemia;  and  the  profound  anaemias, 
pernicious  anaemia,  leucocythaemia,  and  scurvy.  Haematemesis  may  also 
occur  in  high  arterial  pressure,  coming  on  in  the  course  of  granular  con- 
tracted kidney.  Haematemesis  occurring  as  a  feature  of  vicarious  menstrua- 
tion is  a  doubtful  point. 

The  bleeding  in  haematemesis  may  be  slow  or  rapid ;  the  vomiting  of 
the  blood  is  sudden;  and  in  the  majority  of  cases  the  bleeding  is  not 
recognised  till  the  blood  is  seen  in  the  vomit.  In  profuse  bleeding  the 
blood  is  red,  and  consists  of  the  ordinary  elements  of  blood.  In  other 
cases  it  is  clotted  and  may  be  dark ;  and  when  it  remains  for  a  long 
time  in  the  organ,  it  is  of  a  tarry  colour,  and  presents  the  appearance 
of  blackish  granules  in  the  deposit,  commonly  referred  to  as  "coffee 
grounds." 

Symptoms. — The  symptoms  produced  in  bleeding  from  the  stomach 
depend  on  the  amount  of  blood  lost ;  but  are  frequently  overshadowed  by  the 
serious  nature  of  the  primary  disease  present,  such  as  acute  febrile  disease, 
profound  anaemias,  or  cancer  of  the  organ.  Profuse  haematemesis  occurring, 
however,  in  cirrhosis  of  the  liver,  or  in  chronic  ulcer  of  the  stomach,  leads 
to  definite  symptoms.  In  ulcer  it  is  usually  initiated  by  the  partaking  of 
an  indigestible  meal  or  by  some  sudden  exertion ;  the  patient  feels  suddenly 
faint,  with  a  sense  of  warmth,  sinking  or  actual  pain  in  the  epigastrium ; 
the  skin  becomes  cold,  and  may  be  covered  with  a  cold  sweat ;  the  pulse 
is  increased  in  frequency,  small  and  compressible.  Vomiting  may  occur  at 
any  time.  After  the  vomiting  the  patient  feels  relieved ;  in  some  cases 
he  will  be  found  lying  collapsed  upon  the  bed,  with  a  pale,  drawn  face,  and  a 
very  small  compressible  pulse.  Such  symptoms  may  indicate  a  continu- 
ance of  the  bleeding.  Blood  may  be  vomited  once,  twice,  or  three  times  in 
the  same  attack.  After  the  initial  stage  is  passed,  reaction  sets  in ;  the 
first  sign  being  shown,  perhaps,  in  a  faint  flush  of  the  cheeks,  but  more 
commonly  in  the  recovery  of  the  pulse,  which  becomes  full  and  bounding, 
although  still  more  frequent  than  normal.  The  return  of  the  pulse  to 
its  normal  frequency  may  take  some  days ;  and  in  patients  who  are  much 
debilitated  by  chronic  illness,  the  symptoms  of  reaction  are  slight  or 
absent. 

In  haematemesis  an  examination  of  the  stomach  region  may  reveal 
a  diffuse  tenderness  and  no  other  physical  signs ;  or  there  may  be,  as  in 
cases  of  ulcer,  a  localised  area  of  great  tenderness,  with  diffuse  and  slighter 
tenderness  around. 

In  melaena  the  blood  may  come  from  the  stomach  and  duodenum, 
from  the  small  intestine,  from  a  new  growth,  or  from  some  simple  and 
infective  ulceration  of  the  intestine.  In  bleeding  from  the  small  intestine 
or  stomach  the  stools  are  of  a  uniformly  dark  chocolate  colour,  which 
differs  somewhat  from  the  coal-black  colour  imparted  to  them  by  iron,  or 
the  metallic  black  tint  given  by  bismuth. 

Diagnosis. — The  points  to  decide  in  cases  of  haematemesis  are — (1) 
whether  the  stomach  is  the  seat  of  the  haemorrhage ;  (2)  if  the  stomach  is 


DISEASES  OF  THE  STOMACH.  68 1 

the  seat  of  haemorrhage,  the  character  of  the  lesion  present, — whether 
mechanical  congestion,  catarrh,  ulcer,  or  cancer. 

In  some  cases  where  the  blood  has  been  swallowed  there  is  no  difficulty 
in  the  diagnosis ;  this  is  specially  so  in  cases  of  epistaxis.  In  the  case  of 
a  rupture  of  a  large  artery  into  the  upper  alimentary  tract,  death 
usually  ensues.  It  may  be,  however,  difficult  in  some  cases  to  decide 
whether  an  actual  attack  of  haemateniesis  is  due  to  swallowed  blood  from 
the  lungs,  or  to  a  lesion  of  the  stomach  itself,  although  the  difficulty 
is  usually  greater  in  deciding  on  these  points  when  cross-examining  a 
patient  on  his  previous  history.  In  pulmonary  tuberculosis,  haemorrhage 
occurs  in  various  stages  of  the  disease — first,  in  the  early  stage ;  second,  in 
the  progressive  stage ;  third,  in  the  rupture  of  an  aneurysm  in  a  cavity,  an 
event  which  is  usually  fatal.  A  decision  between  haemoptysis  and  hsemate- 
mesis  is  to  be  made  by  an  examination  of  the  mode  in  which  blood  is  brought 
up,  by  the  symptoms  and  physical  signs  present,  and  by  the  examination 
of  blood  and  other  matters  which  are  ejected.  In  both  haemoptysis  and 
hsematemesis  the  bleeding  may  be  at  first  profuse.  Haemoptysis  frequently 
induces  vomiting ;  but  during  the  rest  of  the  day,  or  the  next  few  days, 
bleeding  from  the  lungs  continues,  and  the  patient  brings  up  small 
quantities  of  blood  mixed  with  sputum,  which  will  contain  tubercle  bacilli ; 
and  this,  when  it  occurs,  is  characteristic  of  haemoptysis.  It  does  some- 
times happen,  however,  that  this  continued  spitting  up  of  blood  does  not 
occur,  and  then  the  diagnosis  rests  on  the  physical  examination ;  for,  in 
bleeding  from  the  stomach  due  to  ulcer,  there  is  a  localised  tenderness, 
with  a  previous  history  of  pain  after  food  and  vomiting;  whereas  in 
haemoptysis,  besides  the  history  of  cough,  expectoration,  night  sweats,  and 
wasting,  there  are  the  physical  signs  at  one  or  other  apex  of  the  lung, 
indicating  tuberculous  infiltration. 

In  cases  of  portal  obstruction,  the  existence  of  ascites,  of  pain  and 
tenderness  in  the  liver  region,  of  slight  enlargement  of  the  liver,  and  the 
proof  of  the  alcoholic  habits  of  the  patient,  are  themselves  diagnostic.  If 
the  bleeding  is  due  to  a  general  disease,  the  signs  of  the  disease  are  so 
prominent  as  to  be  easily  detectable  such,  for  example,  as  the  haemate- 
mesis  which  occurs  in  pernicious  anaemia  and  in  leucocythaemia. 

As  regards  the  stomach  itself,  the  diagnosis  lies  between  ulcer  and 
mechanical  congestion  and  cancer,  and  should  be  made  from  the  general 
and  local  symptoms  of  these  diseases.  Cases  of  difficulty,  however,  arise 
as  to  the  cause  of  the  haematemesis  when  chronic  renal  disease  or  mitral 
stenosis  are  present.  In  both  these  conditions  a  tender  stomach  may  be 
present,  leading  to  the  suspicion  of  ulcer  of  the  organ,  when  the  subsequent 
course  of  the  case  shows  that  no  ulcer  is  present. 

Prognosis. — In  profuse  haematemesis  which  is  due  to  ulcer,  the 
immediate  prognosis  is,  as  a  rule,  good ;  but  the  general  condition  of  the 
patient  and  the  special  condition  of  the  stomach  must  be  taken  into 
account,  as  well  as  the  amount  of  blood  lost.  In  cases  of  old-  ulcer,  for 
example,  where  the  patient  is  emaciated  and  worn  out  with  pain,  the 
occurrence  of  haematemesis  frequently  leads  to  death.  In  recent  cases  of 
ulcer,  recovery  is  the  rule.  In  cases  of  portal  obstruction,  of  mitral 
stenosis,  and  of  chronic  renal  disease,  the  haematemesis  is  not  only,  as  a 
rule,  not  serious,  but  is  actually  beneficial  to  the  patient  in  relieving,  in 
the  one  case,  the  venous  congestion,  and  in  the  other  the  high  arterial 
tension. 

Treatment.  —  The   treatment    of    cases    of    haematemesis    may    be 


682 


ALIMENTARY  SYSTEM. 


summed  up  in  rest  to  the  body,  and  rest  to  the  stomach,  and 
abstention  from  all  active  treatment.  The  patient  is  to  be  kept 
in  bed,  and  to  remain  in  a  recumbent  position  in  a  cool  room, 
and  is  not  to  be  excited  by  the  visits  of  friends.  All  feeding  by  the 
mouth  is  to  be  stopped,  rectal  feeding  being  adopted,  and  ice  being 
allowed  to  relieve  the  thirst.  A  tendency  to  syncope  may  be  treated  by 
cold  applications  to  the  temples,  by  inhalation  of  the  vapour  of  ammonia, 
or  by  a  rectal  injection  of  brandy.  Ether  may  also  be  injected  subcu- 
taneously ;  otherwise  more  vigorous  treatment  is  not  to  be  adopted.  No 
stimulants  are  to  be  given  by  the  mouth.  For  the  prevention  of  a  recur- 
rence of  the  haemorrhage,  the  stopping  of  all  food  by  the  mouth  is  usually 
sufficient ;  but  astringents  may  also  be  given,  namely,  tannin  or  gallic  acid 
in  doses  of  2  to  5  grs.,  or  acetate  of  lead  in  1  gr.  doses  in  pill.  These 
must  be  given  every  one,  two,  or  .three  hours.  If  restlessness  and 
excitement  supervene  after  the  haemorrhage,  these  must  be  treated,  either 
by  a  hypodermic  injection  of  2  minims  of  liquor  morphinse,  or  by  a 
rectal  injection  of  15  grs.  of  chloral  hydrate  and  30  grs.  of  potassium 
bromide. 

Excessive  vomiting  and  retching  may  also  be  treated  by  the  hypo- 
dermic injection  of  morphine.  In  the  after-treatment  of  hsematemesis,  be- 
sides the  special  treatment,  which  is  necessary  for  the  conditions  which 
produce  it,  iron  is  to  be  given  in  small  doses  by  the  mouth. 


GASTEIC  ULCEE. 

Ulcer  of  the  stomach  is  a  local  disease  of  the  organ,  commencing  in 
the  mucous  membrane  and  tending  to  spread  through  the  coats,  and 
to  perforate.  It  exists  in  two  forms,  the  acute  and  the  chronic,  both 
of  which  may  lead  to  haemorrhage  and  perforation  of  the  organ.  The 
chronic  tends  to  heal,  and  the  scar  may  produce  a  deformity ;  the  acute 
may  also  heal,  and  rarely  leads  to  deformity.  Erosions  of  the  mucous 
membrane  are  to  be  distinguished  from  ulcer ;  they  are  superficial,  and  on 
healing  leave  a  smooth  scar.  Gastric  ulcer  is  closely  allied,  both  pathologic- 
ally and  clinically,  to  ulcer  of  the  duodenum,  which  may  also  be  acute 
and  chronic. 

Etiology. — Gastric  ulcer  occurs  most  frequently  between  the  ages 
of  15  and  30  years ;  under  15  it  is  rare,  and  after  50  years  the  incidence  of 
the  disease  falls.  Out  of  171  cases  collected  from  the  records  of  University 
College  Hospital,  the  age  incidence  was  as  follows : — 


Between 

0  and  20 

years  . 

15  cases. 

■>■> 

20   „ 

30 

?>       • 

...         75     „ 

3> 

30   „ 

40 

)5 

38     „ 

?} 

40   „ 

50 

J)               • 

.         .         25     „ 

)J 

50   „ 

60 

•>■> 

•         •         H     „ 

Over 

60 

5? 

•         •           4     „ 

Gastric  ulcer  is  from  three  to  five  times  as  frequent  in  women  as  in 
men.  Of  the  171  cases  previously  referred  to,  144  occurred  in  women 
and  twenty-seven  in  men,  a  proportion  of  5 '3  to  1.  It  is  commonest  in  young 
women  under  the  age  of  30 ;  in  men,  however,  the  tendency  to  ulcer 
increases  towards  middle  age. 


DISEASES  OF  THE  STOMACH. 

Age  Incidence  in  Sex  of  Ulcer. 


683 


0  to  20 

years. 

20  to  30 
years. 

30  to  40 
years. 

40  to  50 
years. 

50  to  60            Over  60             T  ,  . 
years.              years.              i-otai. 

Women    . 
Men 

14  cases 
1     „ 

70  cases 
5     ,, 

32  cases 
6     ,, 

15  cases 

10    „ 

10  cases          3  cases 
4     „              1     „ 

144 
27 

Occupation  appears  to  have  but  little  influence  upon  the  production  of 
gastric  ulcer.  Its  frequent  occurrence  in  domestic  servants  and  in  work- 
girls  perhaps  points  to  the  coarse  food  eaten ;  more  especially,  perhaps,  to 
the  large  excess  of  vegetable  food  partaken  of  by  these  people,  containing  an 
excess  of  cellulose. 

Gastric  ulcer  may  exist  by  itself,  and  be  the  sole  organic  disease  present 
during  life  or  found  at  death.  It  may,  however,  be  associated  with  othsr 
diseases,  which  may  of  themselves  be  fatal  or  progressing  at  the  time  cf 
death.  Ague  and  syphilis  are  supposed  to  have  some  relation  to  gastric 
ulcer,  but  the  connection  must  be  a  very  remote  one.  They  are  both 
diseases,  however,  which  produce  anaemia,  and  thus  may  conduce  to  ulcera- 
tion. Tuberculosis  may  be  associated  with  gastric  ulcer,  and  in  some  cases 
of  pulmonary  tuberculosis  it  is  found ;  very  rarely  the  ulcer  is  tuberculous. 
Tuberculosis,  however,  is  not  present  in  cases  of  gastric  ulcer  in  greater 
proportion  than  its  average  incidence  in  individuals  generally.  In  portal 
obstruction  and  in  cardiac  disease, leading  to  embarrassment  of  the  circulation 
of  the  right  side  of  the  heart,  ulcer  of  the  stomach  is  sometimes  found.  Here 
it  may  perhaps  be  considered  that  the  mechanical  congestion  of  the  stomach 
predisposes  to  ulceration.  Chronic  renal  disease  may  also  be  found.  With 
the  chlorosis  of  young  women,  ulcer  appears  to  have  a  definite  connection. 
The  symptoms  of  chlorosis  may  be  present  at  the  time  when  the  symptoms 
of  ulcer  are  observed,  or  there  may  be  a  history  of  some  previous  attack. 
It  may  be  that  in  chlorosis  it  is  the  anaemia,  as  well  as  the  altered  relation 
between  the  arteries  and  the  tissues,  which  predisposes  to  ulceration.  The 
connection  of  amenorrhoea  and  the  puerperal  state  with  ulcer,  is  probably 
only  fanciful.  A  more  definite  connection  is  perhaps  to  be  made  out 
between  gastric  ulcer  and  the  pyaemic  and  septicemic  conditions,  and  the 
same  may  be  said  with  regard  to  duodenal  ulcer.  As  a  rule,  in  these  con- 
ditions the  ulcer  is  acute  and  is  frequently  multiple,  two,  three,  or  more 
being  present ;  and  in  all  probability  the  direct  cause  of  the  ulceration  is 
septic  embolism.  It  is  also  probable  that  the  occurrence  of  gastric  ulcer 
and  of  duodenal  ulcer  in  extensive  burns  of  the  skin  is  associated  with 
embolism. 

Morbid  anatomy.  — Acute  ulcer — The  acute  ulcer  is  usually  small, 
varying  from  half  an  inch  to  one  and  a  half  inches  in  diameter,  and 
has  the  appearance  of  being  punched  out  of  the  walls  of  the  stomach  or 
duodenum.  It  frequently  perforates  ;  the  rupture  of  the  peritoneum  being 
round  or  ragged.  The  edges  of  the  ulcer  are  not  greatly  thickened,  but  are 
congested,  and  the  base  of  the  ulcer  may  show  patches  of  necrosed  tissue. 
Two  ulcers  may  be  found  close  together,  varying  in  size,  or  an  acute  ulcer 
may  be  situated  near  a  large  chronic  one.  The  ulcers  are  situated  chiefly 
in  the  pyloric  region  and,  in  the  duodenum,  usually  in  the  first  horizontal 
portion. 


<S84  ALIMENTARY  SYSTEM. 

Chronic  ulcer. — The  chronic  ulcer  is  funnel-shaped,  the  wider  end  of  the 
funnel  being  at  the  mucous  membrane,  the  smaller  being  situated  near  the 
peritoneal  coat  of  the  organ.  The  edges  are  often  greatly  thickened.  They 
may  be  one  inch  in  thickness.  The  thickening  is  due  chiefly  to  an  increase 
of  the  fibrous  tissue  in  the  submucous  coat ;  but  on  closer  examination 
the  mucous  membrane,  as  well  as  the  muscular  and  peritoneal  coats,  are 
found  thickened.  Sometimes  the  muscle  appears  hypertrophied  towards 
the  edge  of  an  ulcer,  but  this  is  due  chiefly  to  the  solution  of  continuity 
of  the  muscle,  which  retracts.  The  base  of  the  ulcer  is  irregular,  owing  to 
the  ledges  formed  by  the  coats  of  the  organ.  It  may  be  of  a  uniform 
brown  colour,  due  to  the  action  of  the  gastric  juice  on  the  blood  in  the 
superficial  capillaries.  It  may  be  formed  in  the  centre  by  the  peritoneum 
alone,  or  the  peritoneum  may  have  disappeared,  and  the  base  be  formed 
by  the  surface  of  the  liver,  pancreas,  or  spleen.  The  muscular  base  of 
the  ulcer  is  often  extensive.  It  appears  to  resist  the  chronic  ulcerative 
process  to  a  greater  extent  than  the  mucous  membrane.  Not  infre- 
quently part  of  the  base  of  the  ulcer  may  show  a  smooth  scar  where 
healing  has  taken  place,  the  remaining  part  showing  active  ulceration. 
Adhesions  are  formed  between  the  ulcer  and  the  solid  organ,  opposite  to  it, 
most  frequently  to  the  pancreas,  less  frequently  to  the  liver,  and  only 
occasionally  to  the  spleen  or  mesentery.  Adhesion  of  an  ulcer  to  the 
anterior  of  the  abdominal  wall  is  rare,  perforation  being  common  when  the 
ulcer  is  situated  in  the  anterior  wall  of  the  stomach.  The  shape  of  the 
ulcer  is  round  or  oval;  it  may  be  horse-shoe  shaped,  passing  from  the 
posterior  surface  of  the  organ  across  the  lesser  curvature  to  the  anterior 
surface.  In  size  it  varies  from  half  an  inch  to  an  inch,  or  even  as  much  as 
six  inches  in  diameter.  The  ulcer  is  usually  situated  in  the  pyloric  region 
of  the  stomach,  either  on  the  posterior  surface  or  the  lesser  curvature. 
The  following  table,  given  by  Brinton,  of  216  cases  examined  post-mortem, 
shows  the  relative  frequency  of  site : — 

On  the  posterior  surface  ...  86  cases,  equal  to  40  per  cent. 

On  the  lesser  curvature    . 

At  the  pylorus         .... 

On  the  anterior  and  posterior  surfaces 

On  the  anterior  surface  only     . 

On  the  greater  curvature . 

On  the  cardiac. pouch 

The   conclusion   to   be  drawn   is,  that   more  than  three-quarters  of  the 
ulcers  are  to  be  found  in  the  pyloric  region  of  the  stomach. 

Results  of  ulcer. — The  ulcer  may  either  cicatrise  or  perforate. 
Cicatrisation  is  frequent.  According  to  Brinton,  to  156  open  ulcers,  there 
were  147  scars  found  on  post-mortem,  a  proportion  of  13  to  12.  The  scar, 
if  large,  may  by  contracting  distort  the  stomach,  producing  either  great 
puckering  of  the  mucous  membrane,  or  contraction  of  the  middle  of  the 
organ  or  of  the  pyloric  region,  resulting  in  an  hour-glass  stomach,  or  in 
some  cases  producing  an  approximation  of  the  oesophageal  and  pyloric 
openings  of  the  organ.  Ulcers  of  the  pylorus  in  healing  may  lead  to 
pyloric  stenosis.  Perforation  may  either  be  part  of  the  chronic  ulcerative 
process,  or  it  may  be  an  acute  process  added  to  the  chronic ;  or  it  may  be 
due  to  the  rupture  of  the  thin  peritoneal  base  of  the  ulcer  by  some 
muscular  effort.  It  is  most  common  in  ulcers  of  the  anterior  surface,  and 
of  the  greater  curve;  it  also  occurs  in  those  situated  on  the  posterior 


56 

•>■> 

,     26 

32 

33 

,     15        „ 

13 

53 

,         6         „ 

10 

33 

,       4-6    „ 

5 

33 

3       2-3    „ 

4 

33 

o 

3              "               33 

DISEASES  OF  THE  STOMACH.  685 

surface  of  the  organ.  Perforation  may  lead  to  general  peritonitis  or  to 
subphrenic  abscess. 

Pathology. — The  pathology  of  ulcer  of  the  stomach  and  duodenum 
is  very  obscure,  and  no  correct  explanation  of  its  occurrence  is  forth- 
coming. To  produce  ulceration  in  any  part  of  the  body  a  necrosis  or 
death  of  the  tissue  must  first  occur.  The  three  common  causes  of  death 
of  tissue  preceding  ulceration  are — first,  mechanical  and  chemical  causes, 
such  as  corrosive  poisons,  etc. ;  second,  interference  with  the  vitality  of 
the  tissue  by  means  of  blocking  of  the  circulation,  as  in  thrombosis  and 
embolism;  third,  bacterial  infection — the  invasion  of  the  tissue  by 
certain  bacteria  leading  to  death;  and  this  necrosis  may  be  attended 
by  no  signs  of  active  inflammation.  As  regards  the  mechanical  causes  of 
ulcer  of  the  stomach,  there  is  no  evidence  that  an  injury  can  produce  a 
chronic  ulcer.  A  mechanical  lesion  of  the  mucous  membrane  of  the 
normal  stomach  readily  heals,  as  has  been  proved  by  experiment.  Poison- 
ing, however,  by  corrosives,  mineral  acids,  or  alkalies  may  lead  to  chronic 
ulcer  of  the  stomach ;  these  ulcers  may  occur,  not  only  at  the  cardiac 
orifice  but  at  the  pylorus.  Ulceration  of  the  stomach  may  also  occur  from 
pressure,  as  when  an  aneurysm  is  adherent  to  the  organ ;  or,  in  rarer  cases, 
where  there  are  fibro-myomata  in  the  submucous  coat,  which  become 
adherent  to  the  mucous  coat,  and  lead  to  ulceration.  One  such  case  I  have 
known.  Yirchow  promulgated  the  theory  that  a  chronic  ulcer  was 
produced  by  thrombosis  of  the  end  arteries  of  the  stomach,  and  that  the 
shape  of  the  ulcer  is  such  as  would  be  produced  if  the  end  artery  were 
blocked.  It  must  be  said,  however,  that  considering  the  frequent 
occurrence  of  chlorosis  in  association  with  gastric  ulcer,  this  theory  of 
thrombosis  does  not  seem  to  explain  all  the  cases.  There  does  not,  for 
example,  seem  to  be  any  reason  why  thrombosis  should  occur  only  in  the 
stomach  in  cases  of  chlorosis.  Embolism,  however,  is  no  doubt  the  cause 
of  ulceration  which  occurs  in  the  stomach,  and  duodenum  in  septic  and 
pysemic  conditions.  It  is  possible  that  the  -necrosis  which  precedes 
ulceration  may  in  some  cases  be  due  to  the  invasion  of  bacteria.  In  this 
connection  it  must  be  remembered  that  the  most  frequent  site  of  the  ulcer 
is  the  pyloric  region,  the  region  in  which  the  glands  do  not  secrete  hydro- 
chloric acid.  The  hydrochloric  acid  of  the  gastric  juice  is  a  great  inhibitor 
of  bacterial  growth;  and  it  is  not  difficult  to  suppose  that  the  bacteria 
which  are  present  in  the  stomach  contents  may  in  some  cases  persist  when 
there  is  a  diminished  resistance  to  disease;  and  that  they  enter  the  glands 
in  the  pyloric  region,  and  grow  in  the  deeper  parts  of  the  glands  and  in 
the  submucous  tissue.  Although  in  animals  I  have  observed  bacterial 
necrosis  as  a  cause  of  duodenal  ulceration,  yet,  with  regard  to  the  human 
subject,  this  idea  of  the  formation  of  gastric  ulcer  must  be  considered  as 
simple  speculation. 

In  a  large  number  of  cases  of  gastric  ulcer,  especially  in  the  early 
stage,  there  is  hypersecretion  of  hydrochloric  acid,  and  this  is  no  doubt  due, 
partly  to  the  actual  presence  of  an  ulcer,  which  acts  as  an  irritant,  and 
partly  to  the  irritation  produced  by  unsuitable  food.  Hyperacidity,  due  to 
organic  acids,  the  product  of  bacterial  fermentation,  is  of  rare  occurrence 
in  gastric  ulcer. 

A  diminished  acidity  occurs  in  cases  of  gastric  ulcer,  when  associated 
with  pulmonary  tuberculosis  or  with  chronic  catarrh  of  the  stomach,  or  in 
the  later  stages  of  chronic  ulcer,  where  the  patient  has  been  worn  out  by 
pain  and  by  a  diminished  quantity  of  food  during  a  long  period.     The 


686  ALIMENTARY  SYSTEM. 

secretion  of  pepsin  is  not  much  affected  in  the  early  stages  of  gastric  ulcer, 
and  in  these  cases,  indeed,  there  is  usually  a  sufficiency  of  gastric  juice  to 
digest  the  ordinary  meals.  The  movements  of  the  stomach  are,  as  a  rule, 
more  frequently  affected  than  the  secretion,  especially  in  cases  of  chlorosis 
and  of  tuberculosis ;  in  such  cases  there  may  be  well-marked  atony.  In 
other  cases,  however,  there  is  muscular  irritability.  Absorption  is  not 
appreciably  affected.  Bacterial  fermentation  is  practically  unknown  in  the 
earlier  stages  of  gastric  ulcer,  and  when  it  does  occur,  it  is  observed  in  the 
cases  of  hour-glass  contraction  of  the  stomach,  or  in  cases  of  dilatation 
following  long-standing  ulcer. 

Symptoms. — The  symptoms  which  are  characteristic  of  gastric 
ulcer  are  localised  pain  in  the  epigastrium  after  food,  vomiting,  haemate- 
mesis,  and  melaena.  In  addition,  there  may  be  the  symptoms  of  gastric 
irritation  and  of  great  irritability  of  the  stomach.  This  combination  of 
symptoms  is  present  in  the  typical  cases  of  the  disease;  but  there  are 
other  cases  which  may  be  described  as  latent,  inasmuch  as  the  symptoms 
are  indefinite  of  ulcer,  and  are  those  which  have  been  described  as  character- 
istic of  gastric  irritation.  It  is  these  latter  cases  which  give  great  difficulty 
in  the  diagnosis,  and  are  sometimes  only  recognised  by  the  occurrence  of 
hfematemesis  or  of  perforation.  In  all  cases  of  ulcer,  as  well  as  in  cases  of 
functional  disease,  a  complete  examination  of  the  body  has  to  be  made  for 
the  discovery  of  associated  diseased  conditions,  and  in  ulcer  the  chief 
diseases  which  must  be  looked  for  are  chlorosis,  cardiac  disease,  renal 
disease,  and  tuberculosis. 

The  general  symptoms  due  to1  the  presence  of  gastric  ulcer  are,  as  a 
rule,  extremely  few.  The  patient,  in  the  early  stage,  is  well  nourished, 
with  a  moderate  amount  of  subcutaneous  fat.  If,  however,  there  has  been 
a  recent  and  profuse  haematemesis  there  is  well-marked  pallor,  and  if  there 
has  been  repeated  vomiting  there  is  usually  wasting.  There  is  no  fever, 
and  when  this  is  present  it  indicates  either  perforation  and  its  results  or 
not  uncommonly  pulmonary  tuberculosis.  Many  patients  show  an  ex- 
pression of  pain  in  the  face,  which  may  be  anxious-looking.  In  long- 
standing cases  of  ulcer,  the  patient  tends  to  develop  cachexia,  is  thin 
and  weak,  with  a  pale  face,  and  anxious,  tired  expression.  They  show 
myotatic  irritability,  and  the  blood  shows  a  great  reduction  in  the  number 
of  red  blood  corpuscles  and  the  amount  of  haemoglobin  they  contain. 
These  cases  are  associated  with  catarrh  or  with  great  dilatation  of  the 
organ. 

Of  the  symptoms  referable  to  the  stomach,  the  chief  are,  pain,  vomiting, 
and  haematemesis.  The  primary  cause  of  the  pain  is  the  presence  of  an 
open  sore  in  the  stomach  wall,  which  is  irritated  by  the  presence  of  food 
in  the  organ.  It  is  aggravated  and  brought  out  by  the  ingestion  of  food ; 
hy  the  movements  of  the  organ,  which  commence  as  soon  as  food  enters 
the  organ ;  and  by  the  increased  acidity  due  to  hydrochloric  acid.  When 
the  stomach  is  emptied,  either  through  the  pylorus  or  by  means  of 
vomiting,  the  pain  is  relieved?  It  is  sometimes  relieved  by  posture,  the 
relief  so  obtained  being  supposed  to  be  due  to  the  removal  of  the  contents 
of  the  organ  from  the  surface  of  the  ulcer.  So  it  is  said  that  the  pain  of  a 
pyloric  ulcer  may  be  relieved  by  lying  on  the  left  side ;  that  of  an  ulcer  of 
the  posterior  surface,  by  assuming  the  prone  position ;  of  an  ulcer  of  the 
anterior  surface,  by  assuming  the  supine  position.  Pain  is  increased  by 
pressure,  but  in  some  cases  pressure  on  the  epigastrium  relieves  it.  It  is 
felt  in  two  positions,  in  the  epigastric  region  and  in  the  back:  in  both 


DISEASES  OF  THE  STOMACH.  687 

cases  it  is  localised  and  is  associated  with  local  tenderness.  It  may, 
however,  be  circumscribed,  being  observed  over  an  area  only  an  inch  in 
diameter.  In  recent  ha±maternesis  both  the  pain  and  tenderness  may  be 
more  diffuse.  In  the  back  the  pain  is  usually  localised  to  a  region  to  the 
left  of  the  spine,  from  the  tenth  to  the  twelfth  dorsal  and  first  lumbar 
vertebrae.  In  some  cases,  however,  it  is  spread  over  a  larger  area  than 
this.  The  seat  of  the  epigastric  tenderness  is  usually  over  a  small  area, 
above  and  to  the  right  of  the  umbilicus  and  the  xiphisternal  notch,  or  at 
the  notch  itself.  Pressure  on  the  epigastrium,  in  some  cases,  produces 
dorsal  pain.  The  area  of  tenderness  is  the  region  where  the  patient 
experiences  the  greatest  pain  after  eating  or  drinking;  and  the  area  of 
epigastric  tenderness  persists  in  its  circumscribed  form,  without  shifting  its 
locality,  during  the  whole  course  of  the  illness.  In  relapse  of  the  ulcer  the 
same  area  of  tenderness  is  again  discoverable,  although  it  may  have 
previously  disappeared.  The  pain  varies  somewhat  in  character.  It  is 
usually  of  a  heavy  boring  nature,  and  not  sharp  or  shooting,  except  in  rare 
cases.  It  is  usually  described  by  patients  as  going  through  to  the  back 
from  the  epigastrium.  Actual  pain  is  not  usually  felt  when  the  stomach  is 
empty,  and  when  there  is  a  continuous  pain  it  is  usually  due  either  to  the 
great  delay  of  food  in  the  stomach,  to  the  distension  of  the  organ  by  gas, 
and  to  a  condition  of  nervous  irritability,  kept  up  by  injudicious  feeding 
or  by  the  presence  of  chlorosis.  The  pain  comes  on  immediately  after 
a  meal,  and  its  onset  is  due  to  direct  irritation  of  the  ulcer  by  the  solid 
food.  It  is  kept  up  by  the  movements  of  the  stomach  and  by  the 
secretion  of  hydrochloric  acid.  Where  the  pain  comes  on  later,  its  onset 
is  due  to  the  movements  of  the  organ  and  to  the  gradually  increasing 
acidity  of  the  stomach  contents.  In  some  of  these  cases,  however,  there 
is  a  duodenal  ulcer,  and  the  pain  is  only  experienced  when  food  is 
expelled  into  the  duodenum.  Pain  is  directly  relieved  by  vomiting,  and 
when  this  does  not  occur  it  may  last  from  four  to  six  hours,  causing 
great  distress.  In  some  cases  it  is  paroxysmal,  and  may  be  aggravated 
at  the  menstrual  periods.  Sometimes  pain  in  the  chest  is  associated  with 
the  epigastric  pain. 

Vomiting  is  a  symptom  frequently  present,  and  is  sometimes  absent.  Jc 
is  usually  present  if  the  pain  is  severe,  and  it  comes  on  either  directly  after 
the  ingestion  of  food  or  one  or  two  hours  later.  Some  cases  of  gastric 
ulcer  are  characterised  in  their  history  by  attacks  of  continuous  vomiting 
and  retching.  The  vomited  matters  may  consist  only  of  the  undigested  or 
partly  digested  meal,  containing  hydrochloric  acid  and  pepsin,  the  former 
sometimes  in  great  excess.  There  is  no  mucus,  and  bacteria  are  absent. 
Blood  may  be  present,  but  frequently  the  vomit  is  slightly  yellow  in  parts, 
and  on  microscopical  examination  this  is  found  to  be  due  to  the  presence 
of  red  blood  corpuscles. 

Haamatemesis  often  occurs,  and  the  bleeding  may  be  severe  or  slight. 
It  may  occur  at  intervals,  perhaps  of  years,  and  cases  are  not  rare  where 
it  has  occurred  in  girlhood  and  recurred  in  middle  age.  Its  onset  is, 
as  a  rule,  preceded  by  no  warning.  There  may  be  a  feeling  of  faintness 
occurring  after  a  meal  or  some  sudden  exertion,  or  it  may  occur  when  the 
patient  is  in  bed,  after  having  partaken  of  an  indigestible  supper.  Haema- 
temesis  is  of  importance,  inasmuch  as  it  may  be  the  first  notable  symptom 
in  gastric  ulcer.  It  has  been  said  to  occur  in  30  to  40  per  cent,  of 
cases  of  gastric  ulcer,  but  the  percentage  is  probably  much  higher  than 
this.     In  the  171  cases  from  the  records  of  University  College  Hospital, 


688  ALIMENTARY  SYSTEM. 

previously  referred  to,  it  occurred  in  144,  a  percentage  of  about  84.  The 
prof  useness  of  the  haemorrhage  does  not  depend  upon  the  size  of  the  ulcer ; 
a  profuse  and  fatal  haeniatemesis  is  usually  due  to  the  opening  of  a  large 
artery,  such  as  a  branch  of  the  splenic,  of  the  pyloric,  or  of  the  coronary 
artery.  Profuse  haeniatemesis  is  usually  associated  with  melaena.  This 
occurs  in  about  11  per  cent,  of  the  cases.  Out  of  the  171  cases  referred  to, 
melaena  was  observed  in  nineteen.  In  some  cases,  where  the  ulcer  is  near  the 
pylorus,  haematemesis  may  be  absent,  and  melaena  alone  observed. 

Flatulence  is  sometimes  a  severe  symptom  in  gastric  ulcer.  It  is  not 
due  to  bacterial  fermentation  of  the  food,  but  to  swallowed  air,  or  one  of 
the  other  causes  previously  discussed.  The  appetite  is  usually  good,  but 
the  patients  are  afraid  to  eat  owing  to  the  distress  caused  by  the  food ;  the 
appetite  may  even  be  increased.  In  cases  of  long  standing,  however,  the 
appetite  fails.  The  tongue  varies  ;  it  is  usually  clean,  and  not  infrequently 
a  broad,  pale,  flabby,  tooth-indented  tongue,  as  in  anaemia,  is  observed.  The 
bowels  are  usually  constipated.  The  urine  presents  no  great  variation 
from  the  normal;  in  some  cases  albumoses  are  present.  In  the  later 
stages  of  ulcer,  where  there  has  been  a  long  history  of  pain  and  repeated 
attacks  of  vomiting,  and  thus  consequent  starvation,  the  patient  wastes, 
and  a  slight  attack  of  haematemesis  may  produce  a  fatal  result.  In  other 
cases  there  may  be  great  dilatation  of  the  organ,  due  chiefly  to  long- 
continued  atony  of  the  wall,  or  to  stenosis  of  the  pylorus.  There  may  be 
hour-glass  contraction  of  the  organ,  or,  in  rare  cases,  stenosis  of  the  cardiac 
orifice. 

Course  and  duration. — It  has  been  stated  that  80  per  cent,  of  the 
cases  get  well.  Gastric  ulcer  is  a  disease  highly  amenable  to  treatment, 
which  has  as  its  object  the  relief  of  pain,  and  the  giving  of  the  stomach 
sufficient  rest  to  allow  of  the  healing  of  the  ulcer.  Even  with  the  presence 
of  an  open  ulcer  in  the  organ,  there  are  remissions  in  the  disease,  due 
chiefly  to  a  non-irritating  diet  being  taken.  As  a  rule,  however,  patients 
in  this  stage  become  careless,  take  unsuitable  food,  and  a  relapse  occurs, 
which  is  frequently  shown  by  haematemesis  or  by  perforation,  or  simply 
by  the  recrudescence  of  the  epigastric  pain. 

Complications. — Perforation  is  a  frequent  cause  of  death,  and  is  the 
event  most  to  be  dreaded  in  gastric  ulcer.  According  to  Brinton,  in  234 
cases  of  death  from  perforation,  160  were  females,  and  seventy-four 
were  males.  In  statistics  quoted  by  Habershon,  death  from  haemorrhage 
took  place  in  185  cases,  of  whom  108  were  males,  and  seventy-seven, 
women. 

The  frequency  of  perforation  has  been  estimated  by  Brinton  as  13  J 
per  cent,  of  all  cases ;  probably,  however,  it  is  somewhat  higher  than  this. 
It  is  most  frequent  in  young  women,  and  is  most  likely  situated  towards 
the  anterior  surface  of  the  organ.  In  ulcer  situated  on  the  posterior  sur- 
face, the  base  of  the  ulcer  may  be  formed  by  the  pancreas,  spleen,  or  liver ; 
but  perforation  may  occur  and  result  in  the  formation  of  a  subphrenic 
abscess.  In  other  cases,  the  perforation,  especially  from  ulcers  on  the 
anterior  surface,  is  into  the  general  peritoneal  cavity,  and  general  peri- 
tonitis occurs. 

Nearly  80  per  cent,  of  the  ulcers  on  the  anterior  surface  are  said  to  per- 
forate. Death  may  occur  in  a  few  hours  from  shock,  without  the  develop- 
ment of  general  peritonitis.  In  other  cases  the  symptoms  may  be  divided 
into  two  stages ;  in  the  first  of  which  there  will  be  evidence  of  the  rupture 
of  a  hollow  viscus ;  in  the  second,  the  evidence  of  general  peritonitis.     The 


DISEASES  OF  THE  STOMACH.  689 

rupture  usually  occurs  after  a  meal  or  some  sudden  exertion ;  in  a  fit  of 
sneezing  or  coughing,  or  during  vomiting.  There  is  acute  pain,  referred  to 
the  upper  part  of  the  abdomen,  sometimes  doubling  the  patient  up,  as  well 
as  faintness  and  vomiting.  The  pulse  is  rapid,  and  the  features  soon 
become  pinched,  drawn,  and  haggard.  Later  on,  the  abdominal  pain 
becomes  more  diffuse.  On  physical  examination,  it  may  be  found  that  the 
stomach  contents  (gas  and  liquid)  are  retained  in  the  upper  part  of  the 
abdomen,  between  the  stomach,  liver,  and  diaphragm,  or  they  are  present 
in  the  lower  part  of  the  abdominal  cavity.  In  the  first  case  the  physical 
signs  are  those  of  subphrenic  abscess.  The  abdomen  is  generally  moder- 
ately distended,  and  there  is  but  little  movement  of  the  diaphragm  during 
respiration.  There  is  diffuse  tenderness  over  the  stomach  region,  most 
acute  at  the  seat  of  the  perforated  ulcer.  Percussion  may  demonstrate 
gas  and  liquid  in  the  flanks  and  iliac  regions,  but  all  the  liquid  may  be 
collected  in  the  pelvis.  In  the  second  stage,  that  of  peritonitis,  there  is 
fever,  ranging  from  100°  to  102°.  The  expression  of  pain  is  well  marked 
on  the  face,  the  pulse  is  small  and  rapid ;  vomiting  and  hiccough  may  be 
present.  Extreme  rigidity  and  distension  of  the  abdomen  may  obscure 
the  physical  signs  over  the  lower  two-thirds  of  the  abdomen.  Abdominal 
respiration  is  usually  absent. 

Subphrenic  abscess,  formed  below  the  diaphragm,  and  above  the 
liver,  stomach,  and  spleen,  may  occur  from  perforation  of  a  gastric  or 
duodenal  ulcer,  from  the  perforation  from  cancer  of  the  oesophagus  or 
stomach,  from  rupture  of  a  hydatid  cyst,  from  typhlitis,  injury,  gallstones, 
splenic  abscess,  or  perirenal  abscess.  Of  seventy-eight  cases  of  sub- 
phrenic abscess,  collected  by  Nowack,  41  per  cent,  were  due  to  perforating 
ulcer  of  the  stomach  or  duodenum ;  4  per  cent,  were  due  to  perforation 
in  cases  of  cancer  of  the  stomach  or  oesophagus.  In  twenty-nine 
cases  published  by  Maydl,  and  by  Penrose  and  Dickinson,  of  cases  of 
subphrenic  abscess,  the  perforating  ulcer  was  found  on  the  posterior 
surface  in  ten  cases,  on  the  anterior  surface  in  seven,  and  along  the 
smaller  curve  in  twelve.  The  abscess  may  be  either  on  the  left  or  right 
side  of  the  body,  according  to  the  position  of  the  perforating  ulcer :  the 
rupture  of  a  duodenal  ulcer,  or  ulcer  in  the  pyloric  region  of  the 
stomach,  giving  rise  to  right-sided  subphrenic  abscess ;  rupture  of 
an  ulcer  in  the  cardiac  end,  to  a  left-sided  subphrenic  abscess.  The 
boundaries  of  a  right -sided  subphrenic  abscess  are  the  vault  of  the 
diaphragm  above,  the  liver  below,  the  falciform  ligament  of  the  liver  on 
the  left,  and  on  the  right,  the  thoracic  wall.  In  left-sided  subphrenic 
abscess,  the  boundaries  are  the  diaphragm  above,  the  liver  and  anterior 
surface  of  the  stomach  below,  the  abdominal  wall  united  by  adhesions  to 
the  stomach  in  front,  the  falciform  ligament  on  the  right,  and  on  the 
left  it  is  bounded  by  adhesions  between  the  cardiac  end  of  the  stomach, 
the  spleen,  and  the  diaphragm.  Although  primarily  unilateral,  the 
abscess  may  infect  the  other  side.  The  contents  of  the  abscess  are  pus 
and  gas ;  sometimes  they  are  sweet,  sometimes  foul-smelling.  The  remains 
of  food  may  be  found  in  a  recent  abscess.  The  perforation  in  the  stomach 
may  be  patent  or  closed.  An  abscess  in  this  situation  excites  inflammation 
in  the  lung  above,  resulting  in  pleurisy  with  effusion,  empyema,  pneumonia, 
pneumonic  abscess  or  gangrene  of  the  lung ;  and  there  may  be  no  direct 
communication  between  the  abscess  and  the  lung.  Of  forty-five  cases 
collected  by  Maydl,  the  pleura  was  normal  in  eleven,  adherent  in  ten, 
contained  a  serous  fluid  in  nine,  and  pus  in  fifteen  cases. 
vol.  1. — 44 


690  ALIMENTARY  SYSTEM. 

The  development  of  subphrenic  abscess,  due  to  gastric  ulcer,  is  preceded 
by  the  symptoms  which  have  been  described  as  occurring  in  perforation  of 
the  stomach  or  duodenum.  There  is  fever  to  a  slight  extent,  with 
dyspnoea,  but,  as  a  rule,  no  cough  or  expectoration.  The  general 
condition  indicates  a  severe  illness.  A  physical  examination  shows  the 
following  points.  In  many  cases  the  heart's  apex-beat  is  displaced  hori- 
zontally away  from  the  diseased  side.  The  side  is  but  slightly  bulged, 
and  the  respiratory  movements  are  deficient.  In  some  cases,  abdominal 
respiration  ceases,  in  others  it  is  present.  A  thrill  may  be  elicited  over 
the  abscess,  in  some  cases,  by  a  sudden  jerking  movement  given  to  the 
abdominal  wall.  The  liver  may  be  displaced  downwards,  even  to  the  level 
of  the  umbilicus.  In  left-sided  abscess  the  spleen  does  not  usually  come 
below  the  costal  margin.  Over  the  lower  part  of  the  thorax  there  is  a 
tympanitic  note,  the  upper  limit  of  which  is  sharply  marked  off  from  the 
resonance  obtained  over  the  lung.  The  liver  dulness  may  be  completely 
absent,  a  tympanitic  note  being  obtained  over  it.  A  similar  note  may  also 
be  obtained  over  the  lower  part  of  the  cardiac  area ;  posteriorly,  there  may 
be  dulness  when  the  patient  is  lying  down.  The  physical  signs  of  percus- 
sion are  frequently  obscured  by  the  presence  of  consolidation  of  the  lung, 
or  by  fluid  in  the  pleura.  Auscultation  gives  valuable  signs.  Vesicular 
breath  sounds  are  heard  over  the  lung,  down  as  far  as  the  edge  of  the 
abscess ;  while  over  the  tympanitic  resonance  the  breath  sounds  are 
replaced  by  amphoric  breathing;  and  over  the  area  of  dulness  they  are 
absent.     The  bell  sound  may  be  obtained. 

Diagnosis.  —The  association  of  symptoms  which  have  been  described 
are  very  characteristic  of  gastric  ulcer.  The  typical  symptoms  are  not 
always  present,  or  one  may  be  present,  such  as  pain,  heematemesis  being 
absent;  or  haematemesis  may  be  present,  without  any  very  definite  pain. 
For  the  diagnosis  of  the  causes  of  haematemesis  other  than  gastric  ulcer,  the 
paragraph  on  this  subject  must  be  referred  to  (p.  676).  Pain  after  food  is 
present  in  other  diseases  of  the  stomach  besides  gastric  ulcer — in  nervous 
dyspepsia,  in  gastric  catarrh,  and  in  cancer  of  the  stomach. 

In  a  young  woman,  the  subject  of  chlorosis,  where  there  is  no  renal 
disease  and  no  cardiac  disease,  the  presence  of  localised  epigastric  and 
dorsal  pain,  with  tenderness  coming  on  after  food  and  relieved  by  vomiting, 
is  sufficient  for  the  diagnosis  of  gastric  ulcer,  whether  haematemesis  be 
present  or  not.  On  the  other  hand,  in  such  patients,  haematemesis  may  be 
the  first  symptom  noticed,  and  its  occurrence  in  association  with  slight 
dyspeptic  symptoms  is  sufficient  for  the  diagnosis.  The  significance  of  the 
local  pain  and  tenderness  is  as  great  in  middle-aged  as  in  young  women ; 
but  there  is  more  tendency  in  the  middle-aged  to  the  recurrence  of 
haematemesis,  due  to  mitral  disease  or  chronic  renal  disease,  than  in  the 
young  adult.  Gastric  ulcer  must  be  diagnosed  from  gastric  catarrh,  nervous 
dyspepsia  and  gastralgia,  cancer  of  the  stomach,  cholelithiasis,  and  duodenal 
ulcer. 

In  the  majority  of  cases,  ulcer  of  the  stomach  cannot  be  mistaken  for 
gallstones,  inasmuch  as  the  pain  in  the  latter  is  not  situated  in  the  stomach 
region,  but  to  the  right  of  it,  and  is  extremely  severe,  extending  all  over 
the  right  hypochrondrium  and  to  the  front  of  the  abdomen.  The  history 
of  the  patient  may  be  distinctive,  the  localised  pain  and  tenderness  and 
history  of  haematemesis  pointing  to  ulcer ;  the  history  of  long  intervals 
between  the  attacks  of  pain,  with  the  occurrence  of  jaundice  and  tenderness 
of  the  liver,  pointing  to  biliary  colic.     In  the  majority  of  cases,  duodenal 


DISEASES  OF  THE  STOMACH.  O91 

ulcer  is  not  diagnosed  during  life.  It  may  be  suspected,  but  it  may  give 
rise  to  no  characteristic  symptoms  until  it  causes  death  by  haemorrhage  or 
perforation. 

Of  151  cases  collected  by  Perry  and  Shaw,  there  were  no  records  of  notice- 
able symptoms  in  ninety-one  cases ;  in  sixty  cases  there  was  hamiatemesis  and 
nielaena  in  twenty-three ;  but  in  many  cases  there  were  only  vague  dyspeptic 
symptoms  during  life.  There  may  be  great  pain  following  the  ingestion  of 
food,  and  localised  in  the  right  hypochrondrium.  This  pain  will  occur 
some  time  after  food,  and  if  associated  with  melsena  is  suggestive  of 
duodenal  ulcer;  but,  as  in  gastric  ulcer,  hasniateinesis  may  occur.  In 
duodenal  ulcer,  diarrhoea  may  be  a  symptom ;  but  it  is  extremely  rare  hi 
gastric  ulcer.  It  is  impossible  for  the  diagnosis  between  gastric  and 
duodenal  ulcer  to  be  made  in  the  majority  of  instances. 

The  diagnosis  of  rupture  of  a  gastric  ulcer  from  rupture  of  any  other 
part  of  the  intestinal  tract  is,  in  some  cases,  of  great  difficulty.  Symptoms 
of  shock,  followed  by  those  of  general  peritonitis,  are  common  to  rupture 
of  any  hollow  viscus.  In  typhoid  fever,  the  diagnosis  is,  as  a  rule,  not 
difficult,  owing  to  the  history  of  the  preceding  acute  illness.  In  rupture 
of  a  duodenal  ulcer,  no  diagnosis  is  possible  from  that  of  gastric  ulcer. 
The  points  to  be  looked  for  in  the  diagnosis  of  the  latter  are,  the  occur- 
rence of  pain  in  the  upper  part  of  the  abdomen,  the  absence  of  abdominal 
respiration,  the  distension  of  the  abdomen,  and  the  physical  signs  in  the 
upper  part  of  the  abdomen,  which  will  be  described  as  subphrenic  abscess. 

It  is  not  always  easy  to  decide  in  subphrenic  abscesses  whether  the 
collection  of  pus  is  above  or  below  the  diaphragm.  Indications  of  its  being 
below  the  diaphragm  are  the  history  of  the  illness  ;  the  replacement  of  the 
normal  liver  dulness  by  an  area  of  tympanitic  resonance ;  and  the  signs  of 
pneumothorax  over  the  abscess.  When  the  subphrenic  abscess  is  compli- 
cated by  a  large  pleural  effusion,  or  by  consolidation,  or  abscess  of  the  lung, 
the  diagnosis  of  subphrenic  disease  may  be  impossible  until  the  operation ; 
the  symptoms  and  signs  of  disease  of  the  lung  obscuring  those  of  the 
abscess  below  the  diaphragm. 

Abscesses  occurring  on  the  right  side  of  the  abdomen  may  be  due  to 
typhlitis,  or  to  perinephritis,  or  to  gastric  ulcer ;  on  the  left  side,  to  ulcer 
or  disease  of  the  colon  or  kidney.  The  diagnosis  in  these  cases  rests  on 
the  previous  history  of  the  patient,  to  a  great  extent,  on  the  presence  or 
absence  of  pus  in  the  urine,  and  in  the  cases  of  typhlitis,  on  the  presence 
of  the  signs  of  disease  in  the  right  iliac  region. 

Prognosis. — As  a  rule,  the  prognosis  is  good.  Not  only  do  many 
cases  recover,  but  their  treatment  is  so  clearly  indicated,  that,  if  adopted, 
healing  of  the  ulcer  occurs.  Accidents  may,  however,  happen  at  any  time, 
such  as  perforation  or  haematemesis,and  the  only  means  of  guarding  against 
these  results  is  by  treatment.  To  some  extent  the  prognosis  depends  on 
the  associated  disease,  of  which,  as  a  rule,  the  two  most  serious  are  renal 
disease  and  tuberculosis.  No  prognosis  can  be  made  from  the  size,  depth, 
or  position  of  the  ulcer,  since  there  are  no  symptoms  or  physical  signs 
enabling  the  diagnosis  of  these  points  to  be  made. 

Unless  operated  upon,  cases  of  subphrenic  abscess  end  fatally,  by  pro- 
ducing putrid  empyema  or  abscess  of  the  lung,  or  general  peritonitis.  The 
pus  may  be  discharged  through  the  lung,  or  into  the  peritoneal  cavity. 
Of  178  cases  collected  by  Maydl,  ninety-eight  died  without  operation,  six 
healed  without  operation ;  and  of  the  seventy-four  operated  on,  thirty-five 
died  and  thirty-nine  recovered.      It  may  therefore  be   looked  upon 


692  ALIMENTARY  SYSTEM. 

practically  a  fatal  disease,  unless  relieved  by  operation.  The  treatment  is 
indeed  purely  surgical.  In  untreated  cases  of  perforated  gastric  ulcer,  the 
results  are  usually  fatal,  either  from  shock  or  from  general  peritonitis. 
Recovery,  however,  has  been  recorded. 

Treatment. — The  two  objects  to  be  borne  in  mind  in  the  treatment 
of  ulcer  of  the  stomach  are — (1)  to  promote  the  healing  of  the  ulcer ;  (2)  to 
relieve  the  symptoms  of  the  disease.  These  objects  are  gained  by  giving 
physiological  rest  to  the  stomach.  Bodily  rest  is  essential  in  the  treatment 
of  all  cases  of  gastric  ulcer  with  active  symptoms.  A  non-irritating  and 
digestible  diet  is  also  an  essential,  and  in  some  cases  the  food  must  be 
withheld  completely  from  the  mouth,  and  given  by  rectum.  Gaseous 
extension  of  the  stomach  is  also  to  be  prevented,  and  any  general  condition 
of  the  body  present,  such  as  anaemia,  appropriately  treated.  With  this 
physiological  rest,  the  symptoms — pain,  vomiting,  hyperacidity,  flatulence, 
constipation,  hsematemesis — which  have  to  be  treated,  abate,  and  this  end 
is  gained,  not  only  by  a  proper  diet,  but  by  medicinal  treatment.  Cases  of 
ulcer  of  the  stomach  come  under  treatment  in  different  stages  of  the 
disease.  They  may  be  only  suspected  cases — i.e.  first,  those  in  which  no 
definite  symptoms  of  ulcer  have  occurred ;  second,  there  may  have  been 
a  recent  bleeding  in  the  stomach,  or  the  bleeding  may  occur  while  the 
patient  is  under  observation ;  third,  there  may  be  a  history  of  hsemate- 
mesis some  time  previously,  but  symptoms  of  ulcer  are  still  present,  as  is 
shown  in  pain,  tenderness,  and  vomiting ;  fourth,  the  case  may  be  a  long- 
standing one,  and  the  patient  may  show  signs  of  dilatation  of  the  stomach 
and  of  profound  anaemia,  with  wasting.  Suspected  cases  of  ulcer  are  to  be 
treated  as  if  the  diagnosis  were  clear ;  cases  in  which  there  has  been  recent 
hsematemesis  have  to  be  treated  on  the  lines  laid  down  on  p.  679.  Cases  in 
which  there  is  dilatation  of  the  stomach  are  to  be  treated  as  advised  on 
p.  624.  We  have  here  to  consider  the  treatment  of  such  cases  as  show 
localised  pain,  tenderness,  and  vomiting,  without  recent  hsematemesis.  In 
those  cases  vomiting  is  not  uncommonly  a  frequent  symptom ;  the  patient 
can  hardly  retain  any  food  in  the  stomach.  There  may  be  cases  where 
food  causes  severe  pain.  It  is  best  to  commence  treatment  by  withholding 
all  food  from  the  mouth,  and  to  continue  rectal  feeding  for  a  period  of 
two,  three,  or  four  weeks,  ice  being  allowed  for  the  relief  of  thirst. 
Rectal  injections  have  previously  been  considered.  If  there  is  any 
difficulty  in  the  retention  of  the  nutrient  enemata,  5  or  10  drops  of 
tincture  of  opium  may  be  added  to  them,  or  the  nozzle  of  the  syringe  may 
be  smeared  with  cocaine  ointment.  This  treatment,  by  means  of  rectal 
injections,  is  extremely  serviceable  in  affecting  a  cure  in  aggravated  cases 
of  gastric  ulcer.  In  many  cases,  however,  it  need  not  be  resorted  to,  and 
food  may  be  given  in  a  liquid  form  by  the  mouth.  Milk — either  the  full 
milk  or  separated  milk  (sterilised) — is  to  be  given  in  small  quantities 
frequently  during  the  day  and  night ;  and  if  the  full  milk  causes  much 
pain,  separated  milk  alone  is  to  be  used.  In  some  cases  it  is  advisable  to 
begin  the  treatment  by  using  peptonised  milk.  Beef  tea  or  beef  jelly  may 
be  given  occasionally  for  a  change,  and  the  milk  may  be  flavoured  either 
with  coffee  or  tea.  In  changing  from  the  liquid  to  the  solid  diet,  great 
care  is  to  be  exercised  in  watching  the  effect  of  any  addition  of  solid  food 
to  the  dietary.  It  is  usual  to  begin,  once  a  day,  with  finely  divided  crumb 
of  bread  boiled  in  milk,  and  if  this  agrees,  to  proceed  in  a  few  days  to 
pounded  boiled  fish,  or  minced  chicken  or  chop.  The  addition  of  meat, 
however,  to  the  dietary  must  be  very  carefully  considered.     The  great 


DISEASES  OF  THE  STOMACH.  693 

indication  of  the  solid  food  not  doing  harm  is  the  absence  of  pain  in  the 
epigastrium  ;  and,  as  a  general  rule,  it  may  be  stated  that,  as  long  as  there 
is  much  pain  in  the  epigastrium  after  food,  solid  food-stuff's  must  be 
withheld,  and  the  patient  must  be  kept  at  rest. 

As  regards  medicinal  treatment,  acids  are  as  a  rule,  inadmissible,  and 
alkalies  after  meals  are  of  great  service  in  counteracting  the  hyperacidity 
which  frequently  occurs.  They  may  with  advantage  be  combined  with 
sedatives  for  the  relief  of  the  pain  and  vomiting ;  thus,  15  gr.  of  bicarbonate 
of  sodium  may  be  given,  with  3  minims  of  dilute  hydrocyanic  acid,  and  5  to 
10  minims  of  liquor  morphinse  hydrochloratis.  In  other  cases,  cocaine  acts 
well  in  doses  of  ^  gr.  of  the  hydrochlorate, given  in  pill;  bromide  of  potassium 
is  also  of  great  service.  Flatulence  may  be  relieved  by  giving  one  of  the 
antispasmodics  previously  mentioned ;  and  constipation  is  to  be  treated  as 
already  mentioned.     All  violent  purgatives  are  to  be  avoided. 

Under  careful  treatment  patients  suffering  from  gastric  ulcer  improve, 
and  a  great  amelioration  of  the  symptoms  takes  place  within  a  fortnight 
or  a  month.  Whenever,  however,  the  patient  feels  better,  he  is  apt  to  take 
too  much  food,  and  even  indigestible  food,  and  thus  to  have  a  relapse ; 
whereas,  for  a  long  time — it  may  be  a  year  or  more — he  should  consider 
himself  a  dietetic  invalid. 

In  perforation  and  subphrenic  abscess  the  only  treatment  is  surgical. 
The  objects  of  an  abdominal  section  are  to  cleanse  the  peritoneal  cavity 
of  the  extruded  gastric  contents,  and  to  close  the  opening  of  the  ulcer. 
The  decision  as  to  the  closing  of  the  ulcer  depends  on  its  accessibility  and 
on  the  adhesions  round  it.  Further  surgical  treatment  need  not  be 
discussed  here. 

CANCER 

Cancer  of  the  stomach  is  frequently  a  primary  disease  of  the  organ, 
affecting  usually  the  pylorus,  but  also  the  cardiac  orifice  and  the  mid-region 
of  the  stomach.  Cancer  of  the  oesophagus,  in  rare  instances  only,  spreads 
through  the  cardia,  and  secondary  growths  in  the  stomach  occur  from  exten- 
sion from  growths  in  the  neighbourhood,  and  only  in  the  form  of  multiple 
nodules.  In  this  way  sarcoma  may  affect  the  stomach,  primary  sarcoma 
of  the  organ  being  extremely  rare. 

Etiology. — The  etiology  of  cancer  of  the  stomach  is  that  of  cancer 
elsewhere,  and  need  not  be  discussed  in  this  place.  Cancer  of  the  stomach 
occurs  at  middle  age.  Of  600  cases  collected  by  Brinton,  three-fourths 
occurred  between  the  ages  of  40  and  70,  and  the  greatest  number 
between  the  ages  of  50  and  60.  The  disease  may  occur,  however, 
in  young  adults,  and  these  are  usually  cases  of  colloid  carcinoma.  To 
some  degree  there  is  a  predisposition  in  males  to  cancer  of  the  stomach.  In 
fifty-three  cases  collected  from  the  records  of  University  College  Hospital, 
thirty-two  occurred  in  males,  and  twenty-one  in  females.  There  is  no  definite 
relation  between  previous  disease  of  the  stomach,  whether  functional  or 
organic,  and  the  development  of  cancer.  It  may  occur  in  the  chronic 
dyspeptic,  or  in  those  who  have  had  ulcer,  and  Ptosenheim  states  that  5  per 
cent,  of  cases  of  ulcer  pass  into  cancer.  It  might  be  more  correctly  stated  that 
in  5  per  cent,  of  cases  of  ulcer,  cancer  is  subsequently  developed.  Eetrograde 
tuberculosis  of  the  lungs  is  not  infrequently  found  in  patients  who  have 
died  of  cancer. 

Morbid  anatomy. — The  forms  of  cancer  which  are  found  in  the 


694  ALIMENTARY  SYSTEM. 

stomach  are  scirrhus,  columnar,  medullary,  and  colloid  carcinoma.  Scirrhus 
forms  about  three-fourths  of  the  cases.  Colloid  cancer  is  present  in  about 
9  per  cent,  of  the  cases,  and  is  the  form  usually  found  in  young  adults. 
It  is  unnecessary  here  to  describe  microscopically  the  character  of  these 
various  forms  of  cancer.  Of  great  importance  is  the  locality  of  the  new 
growth,  inasmuch  as  according  to  its  position  so  is  the  effect  on  the 
stomach.  The  parts  of  the  stomach  where  the  new  growths  may  be 
situated  are,  in  the  order  of  frequency,  the  pylorus,  the  lesser  curvature, 
the  cardia,  and  the  greater  curvature.  There  is  another  form  of  cancer 
which  is  diffuse,  infiltrating  the  stomach  generally,  and  this  may  also  result 
from  any  of  the  local  growths. 

Brinton  found  the  pylorus  affected  in  60  per  cent,  of  the  cases,  Hahn 
in  only  35  per  cent. ;  the  lesser  curvature  in  16  per  cent,  of  the  cases, 
the  cardia  in  10  per  cent.,  while  the  greater  curvature  is  but  rarely 
affected. 

The  chief  change  that  occurs  in  cancer  is  one  of  degeneration  and 
ulceration,  so  that  a  growth  which  previously  produced  stenosis  may 
ulcerate,  so  as  to  again  open  the  passage.  Adhesions  are  formed  to  the 
neighbouring  organs,  especially  to  the  liver.  The  colon  may  be  adherent 
to  the  stomach,  and  a  fistula  be  formed,  or  in  some  cases  there  may  be  an 
abdominal  fistula.  Thrombosis  of  the  inferior  vena  cava,  or  of  the  portal 
vein,  may  occur,  as  well  as  pressure  on  and  obstruction  of  the  thoracic  duct. 
Secondary  growths  occur  in  about  48  per  cent,  of  the  cases.  They  are 
most  frequent  in  the  liver;  thus,  of  fifty-three  cases  collected  from  the  records 
of  University  College  Hospital,  the  liver  was  affected  in  eighteen  cases,  or 
30  per  cent. ;  the  peritoneum  was  affected  in.  17  per  cent,  of  the  cases.  In 
some  cases  there  is  cancerous  peritonitis,  either  general  or  limited  to  the 
pelvic  region.  The  lungs  may  show  discrete  nodules.  Of  the  other  effects 
of  the  growth  may  be  mentioned  ascites,  which  is  present  in  the  later 
stages  of  cancer,  and  is  due  either  to  cancerous  peritonitis  or  to  portal 
obstruction.  Jaundice  may  also  be  present,  due  to  the  liver  being  invaded. 
The  kidney  may  be  found  cirrhotic,  and  the  heart  is  usually  fatty. 

Pyloric  stenosis  is  frequently  the  result  of  cancer.  The  growth  may 
be  either  fungating,  or  it  may  be  hard  and  infiltrating.  Dilatation  and 
hypertrophy  of  the  stomach  follows  the  stenosis.  In  some  cases  a  diffuse 
infiltration,  with  slight  pyloric  obstruction,  occurs,  and  the  stomach 
assumes  the  form  of  an  oval  bag,  or,  as  it  is  sometimes  described,  "  like  a 
leathern  bottle."  In  these  cases  the  whole  of  the  stomach  wall  is  fibroid 
and  hypertrophied,  as  well  as  infiltrated  with  cancer.  Obstruction  may 
also  be  caused  by  a  large  fungating  growth  in  the  mid-region  of  the 
stomach,  and  the  cardia  may  be  obstructed,  causing  symptoms  like  those 
of  stricture  of  the  oesophagus.  Perforation  of  the  stomach  occurs  in  about 
4  per  cent,  of  the  cases ;  it  may  result  in  a  subphrenic  abscess,  in  a  gastro- 
colic fistula,  or,  more  rarely,  in  a  gastro-cutaneous  fistula. 

Weakness  or  atony  of  the  muscular  coat  is  one  of  the  earliest  signs  of 
cancer  of  the  stomach.  It  is  most  marked  when  there  is  pyloric  stenosis, 
and  it  is  intensified  by  the  ansemia,  general  weakness,  and  cachexia 
produced  by  disease.  Secretion  may  not  at  once  be  effected,  but  as  the 
disease  progresses  the  hydrochloric  acid  diminishes.  This  diminution  of 
hydrochloric  acid  is  due  partly  to  the  infiltration  of  the  stomach  wall  by 
the  new  growth,  but  also  to  the  general  condition  of  the  body,  and  to  the 
associated  atrophy  of  the  gastric  glands.  The  great  tendency  in  cancer 
with  dilated  stomach  is  to  bacterial  fermentation  of  the  food,  so  that  the 


DISEASES  OF  THE  STOMACH.  695 

prolonged  presence  of  lactic  acid  in  the  stomach  contents  is  an  important 
diagnostic  sign  of  cancer. 

Symptoms. — The  symptoms  present  in  cancer  of  the  stomach  are 
extremely  varied,  and  depend  to  a  great  extent  upon  the  position  of  the 
growth.  In  some  cases  in  which  the  growth  is  situated  in  the  mid-region 
of  the  stomach,  the  symptoms  referable  to  that  organ  are  extremely  few, 
there  being  only  the  general  symptoms  of  malnutrition  and  anaemia 
associated  with  cancerous  disease.  When  the  growth  is  situated  at  the 
pylorus  and  produces  stenosis,  the  symptoms  referable  to  the  stomach  are 
well  marked,  inasmuch  as  great  dilatation  of  the  organ  ensues,  with 
bacterial  fermentation  and  repeated  vomiting.  When  the  growth  is 
situated  at  the  cardia  the  stomach  symptoms  may  be  extremely  few  in 
number,  and  the  signs  of  the  disease  closely  resemble  those  of  stricture  of 
the  oesophagus. 

The  course  of  malignant  disease  may  be  divided  into  three  stages,  in 
the  first  of  which  the  symptoms  are  insidious  and  indefinite ;  in  the  second 
of  which  there  is  developed  a  definite  tumour,  with  increase  of  pain  and 
tenderness ;  and  in  the  third,  preceding  death,  in  which  complications  are 
likely  to  arise. 

Where  a  tumour  cannot  be  recognised,  a  correct  appreciation  of  the 
case  is  very  difficult,  and,  as  a  rule,  the  diagnosis  can  only  be  made  in  the 
second  and  third  stages.  The  signs  and  symptoms  due  to  the  growth  itself 
may  be  summed  up  as  pain  and  tenderness,  haemorrhage,  and  the  existence 
of  a  primary  tumour  and  of  secondary  tumours.  The  pain  is  usually  sharp 
and  shooting,  and  may,  when  it  infiltrates  the  liver,  be  dull  and  boring. 
It  is  localised,  and  is  accompanied  by  local  tenderness.  Malignant  tumours 
lead  to  two  forms  of  haemorrhage ;  one  of  which  is  slow  and  is  due  to  the 
ulceration  of  the  growth,  and  the  other  of  which  is  profuse,  and  often  fatal, 
and  is  due  to  the  opening  of  a  large  vein  or  artery.  The  tumour  itself, 
which  can  at  first  be  felt  as  a  resistance,  increases  and  becomes  nodular. 

The  general  symptoms  of  cancer  are  those  of  wasting,  anaemia,  with  an 
opaque,  earthly,  pallid  complexion,  and  a  sense  of  great  weakness.  Fever 
is  not  present,  unless  there  are  complications,  such  as  the  formation  of  an 
abscess  following  perforation,  or  the  formation  of  a  gangrenous  patch 
outside  the  hollow  viscus.  Death  may  occur  from  exhaustion,  starvation, 
from  haemorrhage,  from  abscesses,  and  from  anaemia  or  bronchitis. 

A  typical  case  of  cancer  of  the  stomach  may  be  described  as  follows : — 
A  patient,  middle-aged,  commences  to  suffer  from  symptoms  of  indigestion 
of  food,  the  chief  signs  of  which  are  loss  of  appetite,  which  may  be 
extreme,  some  nausea,  and  pain  in  the  chest  after  eating.  The  effect  of 
these  symptoms  is  out  of  all  proportion  to  their  severity.  Wasting  is 
rapid,  great  pallor  ensues,  while  there  are  no  physical  signs  of  organic 
disease  in  the  thorax  or  abdomen,  and  no  renal  disease  to  account  for  the 
effect  on  the  general  nutrition.  Vomiting,  irregular  in  its  onset,  follows, 
the  vomit  containing  bacteria,  sarcina,  and  an  excess  of  organic  acids.  The 
stomach  may  be  found  dilated,  and  the  epigastric  pain  is  localised  over  the 
pylorus,  and  is  associated  with  tenderness.  A  tumour  may  here  be  dis- 
covered, nodular  and  movable.  Haemorrhage  may  occur,  although  cases  are 
observed  in  which  haemorrhage  is  never  present.  The  case  is  one  which  goes 
progressively  downwards.  Loss  of  appetite  occurs  in  85  per  cent,  of  the 
cases  of  cancer,  presenting  a  great  contrast  of  ulcer.  The  tongue  is  usually 
broad,  pale,  and  flabby.  Pain  is  present  in  92  per  cent,  of  the  cases ;  the 
seat  is  usually  epigastric,  and  it  may,  like  that  of  ulcer,  spread  through  to 


696  ALIMENTARY  SYSTEM. 

the  back.  It  is  not  necessarily  related  to  the  ingestion  of  food,  and  it  is 
not  greatly  relieved  by  vomiting.  Vomiting  occurs  in  87  per  cent,  of  the 
cases,  and  presents  the  characters  of  dilatation  of  the  stomach  (q.v.). 
Hsematemesis  occurs  in  35  to  40  per  cent,  of  the  cases,  and  is  thus  less 
frequently  observed  than  in  ulcer.  The  blood  is  frequently  tarry  in 
appearance,  or  like  coffee-grounds ;  although  the  presence  of  this  kind  of 
blood  does  not  necessarily  indicate  cancer.  The  wasting  in  some  cases  is 
progressive;  but  in  others — owing  to  the  adoption  of  treatment  for  the 
relief  of  bacterial  fermentation — there  may  even  be  a  slight  gain  in  weight 
at  one  period  of  the  disease.  The  bowels  are  usually  constipated,  diarrhoea 
occurring  in  35  per  cent,  of  the  cases.  Melaena  is  not  a  common  symptom. 
The  urine  presents  the  characteristics  of  those  of  dilatation  of  the 
stomach. 

Two  classes  of  cases  are  met  with,  namely,  those  where  there  is  no 
tumour  to  be  felt,  but  there  is  dilatation  of  the  organ ;  and  those  where  a 
tumour  is  present,  with  or  without  dilatation.  These  present  the  physical 
signs  previously  described.  Peristalsis  may  occur,  being  observed  mostly 
in  cases  of  pyloric  stenosis.  In  cases  where  there  is  diffuse  infiltration 
of  the  stomach,  the  organ  forms  an  oblong  tumour  across  the  abdomen, 
usually  tender  and  hard,  which  cannot  be  inflated.  When  there  is  a  tumour 
present,  it  may  be  discovered  over  the  pylorus,  or  over  the  cardia,  or  along 
the  lesser  curve.  These  tumours  are  hard,  irregular,  movable,  and  tender. 
They  vary  in  some  degree  according  to  their  position,  and  their  movability 
may  be  extremely  marked,  perhaps  over  an  area  with  a  radius  of  4  or 
5  inches.  Such  a  tumour  moves  downwards  on  deep  inspiration,  but  is 
not  affected  to  any  extent  by  expiration.  Frequently  gurgling  is  felt  by 
pressing  the  gas  in  the  stomach  through  the  tumour.  Small  tumours  round 
the  cardia  may  be  discovered  only  by  the  passage  of  the  oesophageal  bougie, 
but  frequently  they  spread  over  the  cardiac  pouch,  presenting  themselves 
as  a  flat  mass  below  the  left  hypochondrium. 

The  secondary  growths  in  the  liver  may  be  so  large  as  to  obscure  the 
stomach  tumour,  and  the  case  may  be  diagnosed  as  one  of  primary  cancer 
of  the  liver;  whereas,  on  a  post-mortem  examination,  it  is  found  to  be, 
primarily,  cancer  of  the  stomach.  Jaundice  occurs  in  about  5  per  cent,  of 
the  cases ;  oedema  of  the  legs  in  about  12  percent. ;  and  albuminuria  is  not 
infrequently  present. 

Course  and  duration. — Cancer  of  the  stomach  is  always  a  fatal 
disease.  It  may  kill  within  a  few  months,  or  cases  may  last  even  thirty- 
six  months ;  the  average  duration  being  probably  about  eighteen  months. 
Amelioration  of  the  condition  may  be  produced  by  careful  dieting,  and 
by  counteracting  bacterial  fermentation  of  the  food. 

Diagnosis. — In  cases  of  cancer  which  present  themselves  with  no 
tumour,  but  with  dilatation  of  the  organ,  there  is  frequently  great  difficulty 
in  diagnosis;  such  dilatation  may  be  due  to  catarrh  or  to  old  ulcer. 
The  history  of  the  case,  which  is  prolonged  in  cases  of  ulcer  and  catarrh, 
must  be  taken  into  account,  as  well  as  the  age  of  the  patient,  and  the 
greater  severity  of  the  symptoms  in  cancer.  When  a  tumour  is  present  in 
the  stomach  region,  it  may  be  a  simple  tumour  of  the  pancreas  or  a  tumour 
of  the  gall  bladder.  The  history  of  the  patient  in  this  instance  separates 
the  case  from  that  of  cancer.  The  presence  of  a  tumour  of  the  pylorus, 
with  great  dilatation  of  the  stomach,  points  to  a  pyloric  stenosis;  that  of  a 
mass  below  the  left  hypochondrium,  associated  with  stenosis,  points  to 
cancer  of  the  cardia. 


DISEASES  OF  THE  STOMACH.  697 

Treatment. — The  treatment  is  only  palliative,  and  is  directed  to  the 
relief  of  pain  by  means  of  sedatives,  especially  morphine,  for  the  relief  of 
constipation,  and  for  the  counteracting  of  the  bacterial  fermentation  of 
food  by  means  of  antifermentatives,  and  the  other  methods  described  in 
the  paragraph  on  "  Dilatation."  The  diet  to  be  adopted  must  be  on  the 
lines  previously  laid  down.  The  surgical  procedures  which  have  been 
carried  out  for  cancer  of  the  stomach  are  mainly  palliative.  Excision  of 
the  pyloric  growth  (pylorectomy)  is  attended  by  a  large  mortality,  but  in 
some  of  the  cases  of  recovery  has  caused  a  great  amelioration  of  the  symp- 
toms. It  is  only  permissible  if  the  growth  be  small.  In  the  majority  of 
cases  the  size  of  the  growth  can  only  be  determined  by  an  abdominal 
section.  The  second  operation,  that  of  gastro-enterostomy,  which  has  been 
performed  in  pyloric  cancer,  is  only  palliative,  and  serves,  by  the  relief  of 
the  pyloric  stenosis,  to  stop  the  bacterial  fermentation  of  the  stomach 
contents.  The  mortality  attending  the  operation  is  high,  but  substantial 
relief,  resulting  in  the  prolongation  of  life,  has  resulted  in  some  cases. 


DILATATION. 

Dilatation  of  the  stomach  is  one  of  the  most  important  conditions  to 
which  the  stomach  is  subject ;  inasmuch  as,  when  dilatation  is  present,  the 
muscular  power  being  deficient,  the  food  is  delayed  in  the  organ,  which 
may,  in  extreme  cases,  not  be  able  to  empty  itself  at  all.  Not  only  is 
there  muscular  weakness  in  dilatation,  but  there  is  also  a  distending  force 
which  keeps  up  the  condition,  and  may  to  some  extent  produce  it. 

Etiology. — The  causes  of  the  muscular  weakness  of  the  stomach 
wall  are  chiefly  two  in  number.  First,  the  stomach  muscles  may  have 
more  work  to  do  than  they  can  accomplish  ;  second,  there  may  be  a  primary 
weakness  of  the  muscular  wall.  The  stomach  may  have  more  work  to 
do  in  the  repetition  of  large  meals  through  a  number  of  years,  so  that, 
especially  towards  middle  age,  the  muscular  power  is  insufficient  to  expel 
the  food  through  the  duodenum,  and  there  is  delay  of  food  in  the  organ. 
But  the  chief  cases  of  dilatation  which  occur  under  this  heading  are  those 
due  to  the  narrowing  of  the  pyloric  orifice.  This  is  usually  due  to  cancer, 
but  may  be  due  to  stricture  caused  by  a  cicatrised  ulcer.  In  organic  obstruc- 
tion the  stomach  hypertrophies,  but  the  permanent  result  is  one  of  dilat- 
ation. Some  cases  are  simple  ones  of  dilatation,  which  occur  as  the  result 
of  primary  weakness  of  the  muscular  wall.  They  are  of  great  importance, 
inasmuch  as  they  are  extremely  common,  and  frequently  the  dilatation 
keeps  up  the  functional  disorder.  "Weakness  of  the  muscular  wall  (atony, 
myasthenia)  occurs  in  cases  of  gastric  insufficiency.  It  is  associated  with 
anaemia,  with  cases  in  which  there  is  disordered  innervation  of  the  stomach, 
as  in  nervous  dyspepsia ;  and  it  also  is  the  sequel  of  acute  febrile  disease, 
such  as  pneumonia,  typhoid  fever,  rheumatic  fever,  scarlet  fever,  measles, 
and  others.  This  last  group  constitutes  a  large  and  important  class  of 
cases. 

The  distending  force  in  dilatation  is  mainly  the  accumulation  of  gas  in 
the  organ,  especially  when  a  large  amount  of  this  is  produced  by  bacterial 
fermentation  of  food.  Practically,  dilatation  of  the  stomach  is  best  classi- 
fied under  the  headings  of  obstructive  and  non -obstructive. 

Obstructive  dilatation. — This  occurs  in — (1)  stenosis  of  the  pylorus, 
caused  by  cancer  or  fibroid  contraction,  as  from  chronic  ulcer ;  (2)  pressure 


698  ALIMENTARY  SYSTEM. 

on  the  duodenum  by  a  new  growth  or  stricture  of  the  duodenum,  follow- 
ing the  healing  of  a  duodenal  ulcer;  (3)  contraction  of  the  pylorus  by 
adhesions  in  chronic  peritonitis;  (4)  traction  of  the  cardiac  end  of  the 
stomach  by  adhesions,  resulting  from  a  severe  and  chronic  left-sided  pleurisy. 

Non-obstructive  dilatation.  —  This  may  be — (1)  a  sequel  of  gastric 
irritation,  in  this  case  frequently  being  only  temporary  in  character ;  (2) 
gastric  insufficiency,  which  accompanies  anaemia  and  follows  acute  febrile 
diseases ;  (3)  a  result  of  subacute  chronic  catarrh. 

Pathology. — The  process  of  digestion  is  imperfect  in  all  cases  where 
there  is  dilatation,  but  varies  according  to  the  cause  of  the  condition.  In 
gastric  irritation,  for  example,  there  is  usually  hypersecretion  of  hydro- 
chloric acid,  associated  with  a  moderate  degree  of  dilatation.  Here  the 
chemical  processes  are  active,  but  there  is  mechanical  deficiency.  In  the 
case  of  gastric  insufficiency  there  is  a  general  diminution  of  the  functions 
of  the  stomach.  In  catarrh  there  is  a  great  diminution,  which  is  more 
marked  in  cancer  of  the  organ.  Cases  of  ulcer  resemble  those  of  gastric* 
irritation,  in  the  fact  that  the  chemical  processes  are  active.  Where  there 
is  a  diminution  of  hydrochloric  acid  in  the  organ,  the  usual  result  of 
dilatation  follows,  namely,  bacterial  fermentation  of  the  food  ;  and,  in  addi- 
tion to  this,  the  pylorus  frequently  allows  the  contents  of  the  duodenum 
to  enter  the  stomach,  so  that  bile,  and  often  pancreatic  juice,  may  be 
found  in  the  stomach  contents.  Gases  also  pass  into  the  stomach  from 
the  small  intestine  and  lead  to  one  form  of  flatulence. 

Bacterial  fermentation. — Numbers  of  bacteria  are  taken  into  the 
stomach  with  food,  but  their  development  is  normally  hindered  by  the  pre- 
sence of  hydrochloric  acid  and  gastric  juice.  The  aseptic  nature  of  gastric 
juice  was  demonstrated  by  Beaumont  in  the  case  of  Alexis  St.  Martin,, 
and  previous  to  him  by  Spallanzani.  There  is  no  doubt  that  this  action 
of  the  hydrochloric  acid  as  an  antiseptic  is  an  important  one,  although  it  is. 
not  judicious  to  go  so  far  as  Bunge  in  saying  that  it  is  the  chief  action 
of  the  gastric  juice.  The  hydrochloric  acid  of  the  stomach  does  not  kill 
the  majority  of  the  bacteria  taken  in  food,  but  hinders  their  development, 
and  the  spores  of  the  bacteria  pass  more  readily  through  the  organ  than 
the  developed  forms.  The  forms  of  bacterial  fermentation  which  occur  in 
the  stomach  are  the  acid  fermentation  and  the  alcoholic  fermentation; 
both  of  these  affecting  carbohydrates.  Putrefaction,  in  which  the  proteids 
are  decomposed,  is  of  rare  occurrence  in  the  organ. 

Acid  fermentation  is  of  three  kinds — lactic  acid  fermentation,  butyric 
acid,  and  acetic  acid  fermentation.  The  lactic  acid  fermentation  is  pro- 
duced by  the  B.  acidi  lactici  (Pasteur,  Lister),  which  is  the  cause  of  sour 
milk,  and  is  found  in  beet  juice  and  in  sour  grapes.  Its  form  is  that  of 
short  thick  cells,  usually  united  in  pairs,  and  forming  spores  in  milk.  For 
its  growth  oxygen  is  necessary,  and  it  can  be  cultivated  on  gelatin  and 
various  liquid  media.  It  decomposes  milk  sugar,  cane  sugar,  dextrine,  and 
mannite,  forming  a  large  quantity  of  lactic  acid,  together  with  carbonic  acid 
gas.  Starch  is  first  converted  into  sugar.  Butyric  acid  fermentation  is 
due  to  the  B.  butyricus.  This  bacillus  occurs  widely  distributed,  and  is 
found  in  decaying  vegetable  infusions  and  old  cheese,  and  in  milk  kept  a 
long  time.  It  consists  of  long  slender  rods,  actively  motile  and  forming 
threads  and  spores.  Oxygen  interferes  with  its  growth.  From  starch, 
dextrine,  and  cane  sugar  it  forms  a  large  quantity  of  butyric  acid  with 
carbonic  acid  gas  and  hydrogen,  and  transforms  lactic  acid  into  butyric 
acid  with  the  formation  of  the  same  gases.     The  acetic  acid  fermentation, 


DISEASES  OF  THE  STOMACH.  699 

due  to  the  Mycoderma  aceti,  does  not  commonly  occur  in  the  stomach ;  the 
acetic  acid  which  is  found  in  some  cases  of  bacterial  fermentation  being 
probably  the  produce  of  the  fermentation  by  yeast.  Sarcina  ventriculi 
(Goodsir)  is  an  acid-producing  micro-organism,  but  its  exact  role  in  bacterial 
fermentation  in  the  stomach  is  not  yet  known.  When  found  in  the  stomach 
it  is  always  a  sign  of  bacterial  fermentation.  It  occurs  in  colourless  or 
brownish  cells,  2-5  ^  in  diameter,  arranged  into  groups  of  eight,  united  into 
larger  masses ;  they  look  like  corded  bales  of  cotton. 

Alcoholic  fermentation,  due  to  one  or  other  variety  of  yeast,  usually 
saccharomyces  ellipsoideus,  occurs  in  the  stomach,  and  from  its  action  on 
carbohydrates  produces  alcohol  with  succinic  and  acetic  acids  and  carbonic 
acid  gas.  Glucose  and  maltose  are  more  readily  acted  on  than  starch,  gum, 
and  cane  sugar.  Alcoholic  fermentation  is  not  nearly  so  common  as  the 
lactic  acid  fermentation  and  butyric.  Putrefaction  is  a  rare  condition  in 
the  stomach,  and  all  that  need  be  said  about  it  in  this  place  is  that  it 
leads  to  the  production  of  acid  bodies,  as  well  as  of  foul-smelling  and 
inflammable  gases.     Poisonous  bodies  may  also  be  produced. 

The  total  amount  of  acidity  of  the  stomach  contents,  due  to  bacterial 
fermentation,  may  be  very  high ;  thus,  in  one  case  it  was  found  to  equal 
the  acidity  of  0'48  hydrochloric  acid,  the  acids  present  being  lactic, 
but  chiefly  butyric  acid.  In  other  cases  acetic  acid  was  the  chief  acid 
present.  The  amount  of  lactic  acid  that  may  be  present  in  the 
stomach  contents  varies  considerably.  It  may  be  0*149  per  cent.,  up  to 
0'63  per  cent. 

The  gases  which  are  eructated  in  cases  of  dilated  stomach,  consist 
chiefly  of  carbonic  acid  and  hydrogen,  sometimes  marsh  gas  and  sulphuretted 
hydrogen  are  present.  If  the  gas  is  inflammable,  as  it  sometimes  is,  this 
quality  is  due  chiefly  to  the  hydrogen  and  marsh  gas  present.  Nitrogen 
and  oxygen,  which  are  present  in  the  eructated  gas,  come  partly  from 
swallowed  air,  and  are  partly  due  to  what  is  called  intestinal  respiration ; 
that  is,  the  interchange  of  gas  between  the  blood  and  the  intestinal 
contents. 

Symptoms. — The  symptoms  of  dilatation  of  the  stomach  are  both 
local — that  is,  referred  to  the  stomach  region — and  reflex.  The  latter 
symptoms  are  the  same  as  those  which  occur  in  other  cases  of  disordered 
digestion.  The  association  of  tetany  with  dilated  stomach  has  not  infre- 
quently been  observed.  It  is  possible  that  the  tetany  and  dilatation  may 
be  part  of  a  general  condition,  that  is,  may  result  from  some  preceding 
infection.  The  stomach  symptoms,  as  a  rule,  have  no  very  direct  reference 
to  the  ingestion  of  food,  although  there  are  many  exceptions  to  this.  The 
symptoms  may  come  on  four,  five,  or  six  hours  after  a  meal,  or  may  come 
on  only  towards  the  end  of  the  day,  or  at  intervals  of  two  or  three  days. 
They  are  epigastric  distress  and  pain,  vomiting  and  gaseous  eructations. 
The  epigastric  distress  and  pain  precede  the  vomiting,  the  pain  being 
diffuse  all  over  the  stomach  region  ;  the  symptoms  are  very  severe,  and  are 
accompanied  by  a  hot  burning  sensation  which  immediately  precedes  the 
act  of  vomiting.  This  gives  relief,  and  patients  get  into  the  habit  of 
exciting  vomiting  in  order  to  relieve  their  distress.  The  amount  of  fluid 
vomited  may  be  as  "much  as  six  pints.  It  possesses  the  characters 
previously  described,  and  may  contain  bile ;  bile,  however,  is  not  constantly 
present  unless  there  is  duodenal  obstruction  beyond  the  end  of  the 
common  bile  duct.  Flatulence  is  frequently  a  severe  symptom,  and  is 
constantly  present.     It   is  very  severe   during   the  accumulation   of   the 


7oo  ALIMENTARY  SYSTEM. 

liquid  in  the  stomach,  but,  after  vomiting,  a  large  quantity  of  gas  may 
accumulate  and  blow  out  the  stomach.  The  presence  of  a  greatly  dilated 
stomach  in  the  abdomen  affects  the  circulation  and  respiration,  and  when 
the  dilatation  is  very  acute,  both  respiration  and  the  action  of  the  heart 
may  be  seriously  embarrassed,  and  death  may  ensue  (Hilton  Fagge).  In 
chronic  dilatation,  dyspnoea  is  frequently  present,  as  well  as  rapidity  or 
irregularity  of  the  pulse,  and  relief  is  given  to  both  these  symptoms  by 
the  removal  of  the  stomach  contents.  The  appetite  is  diminished,  and 
there  may  be  complete  anorexia.  Tn  some  cases  the  appetite  is  retained 
for  a  time,  and  there  may  occasionally  be  hunger.  Thirst  is  a  symptom 
which  is  usually  present,  as  well  as  xerostomia,  and  both  these  symptoms 
may  give  rise  to  great  distress. 

Wasting  is  constantly  observed,  and  there  may  be  emaciation.  The 
loss  is  not  infrequently  very  rapid,  and  the  gain  by  applying  appropriate 
treatment  is  also  frequently  rapid.  The  loss  of  weight,  no  doubt,  is  to  be 
ascribed  to  the  fact  that  the  food  not  only  is  not  properly  digested,  but 
is  not  absorbed.  The  bowels  are  obstinately  constipated.  But  when 
bacterial  fermentation  spreads  along  the  intestinal  tract,  the  motions  may 
be  loose  and  offensive,  and  there  may  be  great  distension  of  the  large  gut. 
As  a  rule,  a  small  quantity  of  urine  is  passed,  of  high  specific  gravity, 
containing  an  excess  of  phosphates  and  a  large  quantity  of  ethereal 
hydrogen  sulphates. 

Physical  examination. — The  physical  signs  vary  according  to  whether 
the  stomach  is  distended  with  liquid  or  gas  or  not,  and  it  may  be  advisable 
to  distend  the  organ  artificially,  by  making  the  patient  drink  15  to  30 
gr.  of  citric  or  tartaric  acid  dissolved  in  half  a  tumbler  of  water,  followed 
by  a  similar  quantity  of  bicarbonate  of  sodium  in  half  a  tumbler  of  water. 
In  some  cases  the  dilated  stomach  retains  more  or  less  its  position  in 
the  epigastrium.  Sometimes,  however,  a  heavy  stomach  sinks  into  the 
abdomen,  a  condition  which  is  called  gastroptosis.  In  the  distended  and 
dilated  stomach  there  is  a  prominent  swelling  over  the  epigastric  region, 
more  commonly  occupying  the  lower  epigastric  and  the  upper  umbilical 
regions.  This  swelling,  which  is  formed  by  the  stomach  tmnour,  is  marked 
by  an  ill -defined  groove,  passing  usually  from  just  above  the  umbilicus 
upwards  in  a  slanting  direction  towards  the  left  hypochondrium.  The 
lower  limit  of  the  tumour  is  not  well  marked,  being  very  indistinct  on  the 
right  and  left  sides.  Peristaltic  action  is  frequently  observed,  and  may  be 
excited  by  rapid  rubbing  of  the  surface  of  the  tumour.  It  is  very  char- 
acteristic, inasmuch  as  the  peristaltic  waves  pass  from  the  direction  of 
the  left  hypochondrium  downwards  to  the  right  towards  the  umbilicus. 
The  waves  do  not  start  exactly  at  the  costal  margin,  but  a  short  dis- 
tance below  it.  Peristalsis  in  this  direction  is  characteristic  of  the 
stomach  contractions.  It  may  be  present,  not  only  when  there  is  stenosis 
of  the  pylorus,  but  in  dilatation  due  to  catarrh  or  to  functional  disorder. 
When  the  stomach  is  empty  no  vermicular  action  is  seen,  and  if  the  dis- 
tension is  very  great  it  is  also  absent. 

By  palpation  the  limits  of  the  stomach  tumour  are  better  defined  than 
by  inspection,  there  being  over  the  stomach  tumour  a  greater  resistance 
than  over  the  rest  of  the  abdomen.  If  greatly  distended,  the  stomach 
tumour  feels  like  a  hard  ball.  Splashing  is  a  sign  which  is  produced  by  a 
sudden  jerk  of  the  hand  placed  over  the  distended  organ.  Pulsation  of  the 
upper  part  of  the  abdomen  may  be  present.  In  some  cases  a  systolic 
epigastric  thrill  may  be  felt.      By   percussion,  the   area  of    the    stomach 


DISEASES  OE  THE  STOMACH.  701 

may  be  sometimes  mapped  out.  In  many  cases,  however,  one 
cannot  rely  on  discovering  dilatation  of  the  organ  by  means  of  percussion. 
In  cases  of  moderate  dilatation,  the  stomach  note,  which  is  short,  high- 
pitched,  and  somewhat  musical,  is  obtained  in  the  lower  part  of  the  left 
axillary  region,  backwards  as  far  as  the  posterior  axillary  line,  upwards 
as  far  as  the  fourth  rib.  The  upper  limit  of  the  stomach  note  varies 
according  to  the  distension  of  the  organ ;  and  if  the  cardiac  extremity 
is  permanently  fixed  by  adhesion,  the  stomach  note  is  permanent  in 
the  axillary  region.  By  auscultation,  splashing  in  the  organ  may  be 
heard  if  the  patient,  for  example,  be  given  two  or  three  ounces  of  water 
to  drink. 

The  area  of  the  stomach  distended  with  gas  is  sometimes  easily  mapped 
out  by  means  of  the  bell  sound  (auscultatory  percussion).  It  is  done  by 
placing  the  end  of  the  stethoscope  over  the  stomach  in  the  epigastrium 
and  tapping  one  coin  on  another  in  radiating  lines  downwards  from  this 
position.  Directly  the  coins  are  moved  away  from  the  surface  of  the  organ 
the  bell  sound  ceases.  Both  stethoscope  and  coins  must  be  pressed  firmly 
on  to  the  surface  of  the  abdomen.  The  presence  of  a  dilated  stomach 
may  be  also  shown  by  the  passage  of  a  sound,  the  end  of  which  may 
be  felt  at  a  greater  curvature,  or  by  determining  the  capacity  of  the 
organ,  for  the  normal  stomach  does  not  retain  more  than  1|  to  2|  pints 
of  liquid. 

Diagnosis. — The  presence  of  a  dilated  stomach  is  indicated  by  the 
physical  signs  which  have  just  been  discussed ;  the  chief  symptoms  being 
the  character  of  the  vomiting  and  the  composition  of  the  vomited  matters. 
This,  however,  only  holds  good  for  cases  of  great  dilatation,  and  in  not  a 
few  cases  the  symptoms  may  be  not  greatly  different  from  ordinary  cases 
of  functional  disorder  without  dilatation,  and  the  condition  of  the  organ  is 
discovered  only  by  a  physical  examination.  Flatulence  is  a  symptom 
which  is  rarely  absent,  and  its  persistence — especially  in  young  adults — 
in  the  absence  of  nervous  dyspepsia,  is  frequently  indicative  of  dilatation 
of  the  'organ.  A  distinction  has  been  made  by  some  between  atony  of  the 
organ  and  dilatation ;  but  the  condition  really  is  one  of  degree :  a  slight 
weakness  of  the  muscular  coat  soon  leading  to  dilatation  if  dietetic  irregu- 
larities are  persisted  in.  Diagnosis  of  the  causation  of  dilatation  of  the 
stomach  is  in  many  cases  very  difficult.  The  decision  rests  as  to  whether 
there  is  pyloric  stenosis  or  not ;  and  if  stenosis  is  present,  whether  it  is 
due  to  cancer  or  to  cicatricial  contraction.  The  presence  of  a  tumour  in 
the  pyloric  region  points  to  pyloric  stenosis ;  but  stenosis  may  be  present 
and  a  tumour  absent. 

The  diagnosis  of  dilatation,  without  pyloric  stenosis,  rests  on  the 
previous  history  of  the  disease,  such,  for  example,  as  the  evidence  of 
catarrh,  or  of  prolonged  functional  disorder  of  the  organ.  In  many  cases 
no  diagnosis  is  possible  until  the  patient  has  been  under  treatment  for 
some  time. 

Prognosis. — Although  the  prognosis  depends  on  the  causation  of  the 
dilatation,  yet  a  great  improvement  takes  piace,  in  many  cases,  whether  there 
is  pyloric  stenosis  or  not,  by  appropriate  treatment ;  and  it  is  remarkable 
how  soon  the  stomach  can  be  made  to  contract  by  means  of  treatment.  It 
recovers  up  to  a  certain  point,  and  the  later  contraction  to  its  normal  size 
takes  a  long  time.  There  are  some  cases,  however,  even  of  functional  dilat- 
ation in  which  prolonged  treatment  seems  to  produce  no  result  as  regards 
the  contraction  of  the  organ,  and  it  has  been  proposed  that  a  portion  of 


702  ALIMENTARY  SYSTEM. 

the  organ  should  be  excised  in  order  to  artificially  reduce  its  size.  In  one 
case  in  which  this  was  done,  the  results  were  beneficial  as  regards  reducing 
the  size  of  the  organ,  but  no  permanent  benefit  was  obtained.  It  must  be 
remembered,  too,  that  owing  to  the  fact  that  early  cases  of  pyloric  stenosis, 
due  to  cancer,  are  with  great  difficulty  diagnosed,  this  operation  ought  not 
to  be  lightly  undertaken. 

Treatment. — The  treatment  of  dilatation  of  the  stomach  is  to  be  on 
the  lines  previously  indicated  in  gastric  irritation.  Where  there  is  great 
delay  of  food  in  the  organ — as  in  pyloric  stenosis,  and  where  there  is  pro- 
nounced bacterial  fermentation — washing  out  of  the  stomach,  preferably  by 
an  antiseptic  solution,  is  essential.  As  a  rule,  washing  out  once  a  day  is 
sufficient,  either  in  the  early  morning  or  in  the  evening  before  going  to  bed. 
The  solutions  which  may  be  used  are — Of  boric  acid,  of  a  strength  of  4  dr. 
to  the  pint ;  permanganate  of  potash,  of  a  light  pink  colour ;  bicarbonate  of 
sodium,  containing  3  to  6  dr.  to  the  pint;  or  common  salt,  containing 
\\  dr.  to  the  pint. 

After  washing  out,  antifermentative  remedies  may  be  administered,  the 
best  of  which  are — Hyposulphite  of  sodium,  in  10-  to  15-  gr.  doses  ;  carbolic 
acid,  5-  to  15-  min.  of  the glycerinum ;  creasote,  1-min.  doses;  salicylic  acid, 
|  to  2  gr.,  much  diluted ;  and  resorcin,  5  gr. 

In  cases  of  subacute  catarrh,  washing  out  of  the  stomach  is  not  to  be 
persisted  in.  It  may  be  performed  once  or  twice  at  the  commencement  of 
the  treatment,  but,  as  a  rule,  not  of tener.  Much  harm  may  be  done  by  per- 
sisting in  washing  out  the  organ  in  all  cases  of  dilatation  of  the  stomach, 
inasmuch  as  after  a  time  the  distension  of  the  organ,  by  a  large  quantity  of 
added  liquid,  prevents  the  recovery  from  the  condition.  Massage,  both 
local  and  general,  is  of  great  benefit  in  dilatation,  especially  when  the 
abdominal  muscles  are  lax,  and  when  there  is  gastroptosis.  In  these  latter 
cases  it  is  frequently  of  benefit  to  wear  an  abdominal  belt,  arranged  so  as 
to  press  the  stomach  somewhat  upwards.  The  local  application  of 
electricity  may  be  of  use,  as  well  as  douching  the  abdomen,  if  the  patient 
can  stand  it. 

Besides  anti-fermentative  remedies,  it  is  frequently  imperative  to  give 
alkalies  to  relieve  the  acidity,  and  antispasmodics  may  be  useful  in  reliev- 
ing flatulence.  The  diet  to  be  given  must  be  regulated  according  to  the 
amount  of  vomiting  and  epigastric  distress  present.  The  only  method  of 
feeding  in  these  cases  is  to  withhold  all  food  from  the  mouth  and  feed  the 
patient  by  rectum.  This  is  specially  useful  in  cases  of  dilatation  of  the 
organ  occurring  in  catarrh  and  in  ulcer ;  but  it  is  also  useful  in  other  cases. 
If  the  patient  can  take  food  by  the  mouth  without  much  distress,  it  is 
advisable  to  give  little  liquid,  and  a  solid  diet  of  digestible  food;  thus, 
patients  have  frequently  been  found  to  do  well  on  minced  mutton,  minced 
chicken,  or  meat  balls,  with  occasionally  a  little  milk.  Carbohydrates 
must  be  withheld  when  there  is  much  bacterial  fermentation. 

SIDNEY  MARTIK 


DISEASES  OF  THE  INTESTINES.  70^ 

DISEASES  OF  THE  INTESTINES. 

ENTEEITIS. 

The  term  enteritis,  or  inflammation  of  some  part  of  the  intestine,  may 
be  applied  in  its  strict  pathological  sense  to  a  large  number  of  morbid 
conditions  which  present  wide  differences  in  causation  and  in  severity. 
The  inflammation  may  attack  any  part  of  the  intestine,  from  duodenum 
to  rectum.  It  may  be  confined  to  the  mucous  membrane,  as  in  catarrhal 
enteritis,  or  may  extend  to  the  other  coats  of  the  bowel,  including  the 
peritoneum,  as  in  the  phlegmonous  enteritis  set  up  by  severe  mechanical 
damage  to  the  bowel.  The  character  of  the  inflammation  varies.  It  may 
be  catarrhal: — that  is,  confined  to  the  mucous  surface  and  accompanied  by 
a  non-coagulable  exudation ;  or  it  may  be  croupous,  and  may  lead  to  the 
death  of  the  mucous  lining  and  the  formation  of  a  membrane  of  coagulated 
exudation,  as  in  croupous  or  diphtheritic  enteritis.  In  many  forms  it  leads 
to  ulceration,  as  in  typhoid  fever  and  tuberculous  disease  of  the  bowels ; 
and  this  ulceration  may  be  so  extreme  as  to  form  the  chief  feature,  and 
lead  to  an  incurable  destructive  loss  of  the  mucous  and  other  tissues,  as  in 
dysentery  and  ulcerative  colitis. 

As  used  in  its  simple  pathological  sense,  the  term  thus  comprises  all 
inflammatory  conditions  of  the  bowels.  In  its  clinical  use,  however,  the 
term  has  a  much  narrower  application.  All  those  conditions,  such  as 
typhoid  ulceration,  tuberculosis  and  dysentery,  which  depend  on  some  specific 
cause  more  or  less  certainly  known,  receive  a  separate  description,  and  the 
term  enteritis  is  commonly  reserved  for  certain  clinical  forms  of  disease 
of  which  the  causation  is  not  so  definitely  known.  The  diseases,  then, 
which  come  into  this  group  are  somewhat  ill  defined.  They  are  loosely 
strung  together  for  clinical  purposes  by  the  fact  that  in  all  of  them 
inflammation  of  some  portion  of  the  bowel  seems  to  play  a  part,  but  it  will 
appear  later  that  the  actual  inflammation  may  be  exceedingly  slight,  and 
that  in  some  forms  it  is  probably  a  bacterial  intoxication  which  is  mainly 
responsible  for  the  symptoms. 

Catarrhal  Enteritis. 

This  is  an  inflammation  limited  to  the  mucous  membrane,  and 
accompanied  by  a  non-coagulable  mucous,  serous,  or  purulent  discharge. 
It  may  affect  any  part  of  the  intestinal  canal,  but  more  particularly  affects 
the  small  bowel.  Clinically  it  is  marked  by  diarrhoea,  usually  attended 
with  pain.  In  adults  it  is  of  comparatively  small  importance,  but  in 
young  children  it  is  attended  with  considerable  danger  to  life,  and  the 
infantile  form  deserves  a  separate  description. 

Etiology. — It  may  be  broadly  stated  that  most  cases  of  catarrhal 
enteritis  owe  their  origin  to  some  irritant,  which  is  either  taken  into  the 
stomach  and  bowel,  or  is  formed  therein  by  some  morbid  process.  Thus, 
food  which  is  improper  or  indigestible  or  excessive  in  amount,  is  the  most 
common  cause,  especially  in  the  case  of  infants ;  and  under  this  head  must 
be  included  also  the  toxic  bacterial  products  which  are  contained  in 
decomposing  food  or  non-sterilised  milk.  The  medicinal  use  of  mercury 
and  arsenic  and  some  purgatives,  and  the  excessive  use  of  the  stronger 


704  ALIMENTARY  SYSTEM. 

forms  of  alcohol,  may  similarly  set  up  an  intestinal  catarrh.  Many 
instances  seem  to  depend  in  some  way  upon  the  weather  and  external 
influences.  Thus  it  may  follow  directly  upon  exposure  to  cold  or  wet,  as 
does  a  catarrh  of  the  respiratory  mucous  membrane.  But  it  is  especially 
common  in  hot  weather  associated  with  drought,  and  it  is  not  unlikely 
that  the  climatic  condition  acts  in  these  cases  through  the  facility  afforded 
for  the  growth  of  bacteria  in  the  food  or  in  the  bowel,  though  nothing 
certain  is  known  on  this  point. 

Lying  somewhat  apart  from  these  forms  is  the  chronic  catarrhal 
condition  of  the  bowels  which  is  apt  to  ensue  upon  the  passive  con- 
gestion associated  with  cirrhosis  of  the  liver  and  chronic  cardiac  disease. 
Finally,  a  similar  condition  may  arise  in  late  stages  of  many  severe 
diseases,  such  as  chronic  Bright's  disease,  pyaemia,  septicaemia,  pernicious 
anaemia,  Addison's  disease,  and  scurvy.  In  such  cases  the  intestinal 
catarrh  may  be  explained,  either  as  a  direct  result  of  the  action  of  some 
circulating  poison  upon  the  bowel,  or  merely  as  an  expression  of  the 
lowered  tissue  resistance  which  accompanies  such  grave  disorders. 

Morbid  anatomy. — There  is  every  reason  to  believe  that  the 
changes  in  the  bowel  are  such  as  occur  in  catarrh  of  mucous  membranes 
elsewhere,  namely,  hyperemia,  swelling,  and  dryness  of  the  mucous 
membrane,  followed  by  an  increased  secretion  of  mucus,  with  shedding  of 
epithelium  and  some  serous  or  even  purulent  exudation,  often  streaked 
with  blood.  There  is,  however,  a  striking  disparity  between  the  violence 
of  the  symptoms  and  the  anatomical  condition.  In  the  post-mortem  room 
very  little  change  is  to  be  seen.  There  may  be  a  visible  excess  of  mucus, 
perhaps  blood-tinged,  clinging  to  the  surface,  with  patches  of  hyperemia, 
and  perhaps  punctiform  haemorrhages  here  and  there.  Sometimes  there 
may  be  slight  swelling  of  the  solitary  follicles,  and,  in  cases  which  are  of 
long  standing,  abrasions  or  shallow  ulcers  (follicular  ulcers)  may  be  found 
on  the  solitary  follicles  and  Peyer's  patches. 

Symptoms. — It  will  be  understood,  from  a  consideration  of  these 
causes,  that  two  classes  of  catarrhal  enteritis  may  be  recognised.  In  the 
first  class,  which  may  be  called  acute,  and  which  arises  from  some 
irritant  or  error  in  diet  or  climatic  condition,  the  cause  has  a  sudden  effect, 
which  is  of  short  duration.  In  the  other  or  chronic  class  the  cause  is 
persistent,  and  the  enteritis  is  often  a  comparatively  unimportant  part  of  a 
general  disease. 

The  main  features  of  an  acute  catarrhal  enteritis  are  diarrhoea 
and  abdominal  pain.  It  is  not  to  be  supposed  that  diarrhoea  is  synony- 
mous with  catarrhal  enteritis ;  but  at  the  same  time  it  may  be  remem- 
bered that  diarrhoea  is  the  most  constant  symptom  of  the  condition. 
The  bowels  are  frequently  moved,  perhaps  every  hour  in  severe  cases.  The 
stools  are  liquid  and  watery,  owing  to  the  profuse  serous  exudation.  But 
they  always  contain  some  bile,  and  are  therefore  yellowish  or  greenish,  and 
rarely,  if  ever,  become  colourless  or  milky,  as  in  cholera.  There  is  consider- 
able pain  in  acute  cases,  which  for  the  most  part  precedes  each  action  of 
the  bowels ;  but  between  the  actions  the  small  intestine  often  shows  a 
violent  peristalsis,  attended  by  colicky  griping  pain  and  borborygmus,  as 
the  fluid  contents  are  forcibly  driven  on  from  section  to  section.  Tenesmus 
or  rectal  straining  is  rare,  and  it  seems  only  to  occur  when  the  catarrhal 
process  affects  the  lower  part  of  the  large  bowel.  The  abdomen  may  be 
unaltered  in  appearance,  or  somewhat  distended.  It  may  become  sensitive 
to  pressure  after  a  few  days  of  the  disease.     The  tongue  is  furred,  but  does 


DISEASES  OF  THE  INTESTINES.  705 

not,  as  a  rule,  become  dry.  The  appetite  is  lost.  There  may  be  occasional 
vomiting  at  the  commencement  of  the  attack,  especially  if  the  stomach  is 
similarly  affected.  The  temperature  is  usually  normal  throughout,  and  it 
seldom  exceeds  101°  for  a  few  days.  In  very  severe  cases,  associated  with 
profuse  diarrhoea  and  great  loss  of  fluid,  there  may  be  some  degree  of 
collapse,  and  in  debilitated  individuals  this  may  give  rise  to  alarm  ;  but  in 
the  majority  of  cases,  where  the  trouble  arises  from  error  of  diet,  or  origin- 
ates in  some  weather-condition,  the  patient  is  himself  again  in  three  or 
four  days,  and  there  is  no  need  for  anxiety.  The  matter  becomes  more 
serious  and  more  difficult  to  treat  when  it  depends  on  some  recurring  or 
constantly  acting  cause,  such  as  a  cirrhotic  condition  of  the  liver.  In  such 
chronic  cases  the  diarrhoea  is  often  profuse  and  uncontrollable,  while  pain 
is  rarely  severe,  and  is  often  entirely  absent. 

The  association  of  a  catarrh  of  the  duodenum  with  a  similar  condition 
in  the  stomach  is  not  uncommon.  It  is  marked  by  a  more  persistent  loss 
of  appetite,  by  more  tendency  to  vomit,  and  by  a  sensation  of  discomfort 
or  tenderness  and  actual  pain  in  the  epigastrium,  and  sometimes  in  the 
back  at  the  same  level.  Diarrhoea  may  be  slight  or  absent.  It  is  in  such 
a  condition  that  a  catarrhal  jaundice  is  apt  to  supervene,  by  an  extension 
of  the  inflammation  to  the  common  bile-duct. 

Treatment. — In  the  milder  cases,  which  are  of  such  frequent  occur- 
rence, the  symptoms  will  often  subside  if  the  patient  remains  in  bed  for  a 
day  or  two,  with  a  diet  limited  to  milk  diluted  with  soda-water  or  lime- 
water  ;  while  hot  fomentations  to  the  abdomen  will  quickly  give  relief  from 
the  griping.  As  the  diarrhoea  ceases,  care  must  be  exercised  in  returning 
to  a  normal  diet,  and  during  the  next  few  days  broths  thickened  with 
bread  crumbs,  milk  puddings,  fish,  and  minced  chicken  may  be  cautiously 
added  to  the  diet.  In  many  cases,  where  the  patient  is  weakly,  or  there  is 
any  collapse,  some  alcohol  may  be  necessary.  If  there  is  clear  reason  to 
believe  that  the  enteritis  is  dependent  on  the  ingestion  of  some  excess  of 
food,  or  of  some  improper  and  indigestible  material,  a  dose  of  1  oz.  of  castor- 
oil  containing  10  minims  of  tincture  of  opium  for  an  adult,  or  a  dose  of  the 
castor-oil  mixture  (B.P.)  for  a  child,  may  be  given  with  advantage  when 
the  patient  first  comes  under  observation.  The  pain  and  diarrhoea  can 
then  be  dealt  with  by  a  few  doses  of  subnitrate  of  bismuth,  with  10  minims 
of  tincture  of  opium  to  the  dose.  In  younger  patients,  10  gr.  of  aromatic 
chalk  powder,  with  2  gr.  of  Dover's  powder,  may  be  used  with  a  similar 
effect.  As  a  rule,  no  other  treatment  is  required,  as  the  natural  tendency 
of  an  acute  catarrh  is  towards  a  rapid  subsidence.  In  those  cases  which 
are  prevalent  in  hot  weather,  and  which  are  not  obviously  dependent  on 
some  error  of  diet,  it  is  advisable  to  use  salicylate  of  bismuth  and  salol, 
5  gr.  of  each.  Occasionally,  in  the  adult,  there  may  be  reason  for  the 
use  of  a  subcutaneous  injection  of  \  gr.  of  morphine. 

In  the  chronic  catarrh  which  has  been  mentioned  as  being  associated 
with  and  secondary  to  some  other  disease,  all  drugs  are  often  found  to 
fail.  The  best  remedies  are  bismuth  subnitrate,  and  astringents  such  as 
dilute  sulphuric  acid,  tincture  of  catechu,  compound  kino  powder,  and 
pernitrate  of  iron. 

Catarrhal  Enteritis  in  Children. 

This  condition  is  common  enough  in  children  of  all  ages,  but  is  more 
particularly  common  and  more  grave  in  young  children  under  2  years  of 
vol.  1.— 45 


706  ALIMENTARY  SYSTEM. 

age.  The  term  dyspeptic  diarrhoea,  which  is  sometimes  used,  explains 
something  of  its  origin.  It  arises  largely  from  the  improper  feeding  of 
infants,  more  especially  of  course  of  hand-fed  infants.  The  feeding  of 
infants  who  from  some  cause  are  deprived  of  the  maternal  nutriment  is 
simple  in  principle,  but  requires  constant  care  and  intelligent  watchfulness 
in  practice.  The  actual  irritant  which  appears  for  the  most  part  to  excite 
this  enteritis  in  young  children  is  either  improper  food,  such  as  excess  of 
milk,  which  they  cannot  assimilate,  or  starchy  matter,  which  they  are  quite 
unable  to  digest,  or  milk  which,  from  want  of  care  and  cleanliness,  has  been 
allowed  to  become  a  rich  field  for  bacteria.  To  these  causes  certain  con- 
ditions, such  as  teething  and  rickets,  often  contribute ;  and  there  is  clear 
evidence,  moreover,  that  the  occurrence  of  enteritis  is  aided  to  some  extent 
by  chill,  produced  by  improper  clothing,  or  by  sudden  changes  of  tempera- 
ture. In  simple  cases  produced  in  this  way,  the  symptoms  are  mainly 
due  to  the  mechanical  irritation  of  the  bowel,  set  up  by  the  unnatural 
quality  or  condition  of  the  food.  Such  cases  are,  of  course,  more  common 
among  the  poor  than  the  rich ;  and  they  are  commonly  mild  and  easily 
remedied,  if  the  child  can  be  placed  under  favourable  conditions.  In  other 
cases,  however,  there  is  reason  to  believe  that  the  symptoms  depend  mainly 
on  a  bacterial  intoxication,  and  these  bacterial  cases,  which  are  of  far 
greater  severity,  would  probably,  if  our  knowledge  permitted,  be  placed 
under  a  separate  heading.  This  form  of  disease  is  a  feature  of  town  life, 
and  it  occurs  among  the  rich  and  the  poor.  It  is  particularly  prevalent  in 
hot,  dry  weather,  and  statistics  show  that  the  mortality  is  greatest  in  the 
months  of  July,  August,  and  September. 

Morbid  anatomy. — There  is  little  to  add  to  what  has  already  been 
said  as  to  the  appearances  seen  in  the  bowels  of  adults  and  older  children. 
There  is  sometimes  an  excess  of  mucus,  and  there  are  often  patches  of 
hyperseniia,  which  are  probably  often  a  post-mortem  phenomenon.  There 
may  be  a  little  swelling  of  the  solitary  and  agminated  follicles,  but  it  must 
be  remembered  that  these  structures  are  always  prominent  in  young 
children.  The  mesenteric  glands  may  be  swollen  and  pink  on  section. 
The  most  obtrusive  post-mortem  evidence  is  given  by  shallow  ulcers  and 
abrasions,  which  are  sometimes  found  on  both  solitary  glands  and  on 
Peyer's  patches.  They  are  most  common  in  the  lower  part  of  the  ileum 
and  upper  part  of  the  large  intestine,  but  they  are  seen  in  those  severe 
and  protracted  cases  only  which  do  not  respond  to  treatment  even 
though  the  apparent  cause  has  been  removed.  As  a  result  of  long- 
continued  catarrh  in  young  children,  there  has  been  described  a  condition 
of  atrophy  of  the  glandular  part  of  the  mucous  membrane,  and  its  replace- 
ment by  cellular  connective  tissue  containing  black  or  slate-coloured 
pigment.  It  has  been  already  stated  that  a  group  of  cases,  at  present 
included  under  this  head,  are  probably  in  part  at  any  rate  of  bacterial 
origin,  and  that  the  severe  general  symptoms  which  ensue  are  dependent 
on  the  absorption  of  poison  developed  in  the  intestines  by  bacterial  life. 
No  specific  organism  is  known.  The  observations  of  Booker,  Vaughan, 
Jeffries,  and  Baginsky  point  to  the  conclusion  that  many  different 
saprophytic  organisms  are  concerned,  but  that  while  no  one  variety  is 
constant,  the  Proteus  group,  and  forms  closely  allied  to  Bacillus  coli  com- 
munis, seem  to  predominate. 

Symptoms. — In  mild  cases  there  is  diarrhoea,  with  a  frequent 
passage  of  greenish  stools,  which  are  slimy  and  offensive,  and  may  show 
visible  mucus.     They  have  been  likened  to  chopped  spinach.     If  an  excess 


DISEASES  OF  THE  INTESTINES.  707 

of  milk  is  tho  cause,  lumps  of  undigested  casein  may  be  recognised.  The 
green  colour  of  the  stools  is  possibly  due  to  some  specific  bacterial  product. 
The  child  may  vomit  occasionally,  but  this  is  not  a  marked  symptom. 
There  is  little  or  no  fever,  and  the  abdomen  is  soft  and  flaccid.  The  child 
quickly  shows  signs  of  general  disturbance.  He  becomes  pale,  there  is 
irritability  and  restlessness,  due  to  pain  or  discomfort  in  the  abdomen,  and 
he  frequently  cries  aloud.  In  many  such  cases,  if  they  are  taken  in  hand 
at  an  early  period,  appropriate  dieting  and  treatment  will  bring  about  a 
cure  in  a  few  days. 

In  some  cases,  especially  those  occurring  during  hot  weather,  the 
symptoms  are  far  more  severe,  or,  at  any  rate,  more  rapidly  attain  to 
a  high  degree  of  severity,  so  that  the  child  is  already  extremely  ill  when 
the  physician  first  sees  him.  The  symptoms  here  are  suggestive  of  a 
bacterial  intoxication,  as  well  as  of  a  malnutrition,  induced  by  imperfect 
absorption  of  food  from  the  alimentary  canal.  The  vomiting  is  more 
frequent,  the  diarrhoea  is  more  urgent,  the  stools  contain  less  and  less 
fsecal  matter,  and  become  more  and  more  fluid,  still,  however,  as  a  rule, 
being  greenish  and  very  offensive.  Mucus  is  occasionally  seen,  but  seldom  in 
large  amounts,  and  blood  streaks  may  be  noticed.  The  abdomen  becomes 
obviously  tender.  It  may  be  distended  with  gas,  but  is  often  shrunken 
and  hollow.  The  child  lies  with  knees  drawn  up  and  legs  crossed,  dreading 
all  handling.  Aphthae  may  develop  on  the  tongue  and  mucous  membrane 
of  the  mouth.  The  general  condition  is  often  alarming,  there  is  obvious 
wasting,  and  nutrition  is  at  a  standstill.  The  face  is  pinched  in  appear- 
ance, the  eyes  become  hollow,  and  the  fontanelle  is  depressed.  The  tongue 
grows  dry,  the  pulse  becomes  rapid  and  feeble.  The  temperature,  after  the 
rule  in  infantile  diseases,  is  very  variable.  It  may  quickly  become  sub- 
normal, and  remain  so  until  death  or  recovery ;  or  a  moderate  fever  may 
set  in,  or  the  temperature  may  rise  rapidly  till  a  fatal  termination  is 
reached.  The  urine  is  commonly  diminished  in  amount.  At  any  period  a 
collapse  may  set  in,  which  can  only  end  in  death.  In  some  instances, 
occurring  during  hot  weather,  collapse  may  set  in  with  a  suddenness  and 
rapidity  suggestive  of  English  cholera  (cholera  nostras),  and  the  distinction 
between  the  two  conditions  is  sometimes  exceedingly  slight.  Death  may 
occur  in  three  days  from  the  onset.  In  other  instances  which  are  of  longer 
duration,  convulsions  or  broncho-pneumonia  may  end  the  scene. 

There  must  also  be  described  a  chronic  class  of  enteritis,  which  is 
induced  by  a  long  course  of  improper  feeding,  and  is  often  complicated  by 
rickets.  There  is  either  a  succession  of  slight  attacks  of  moderate  enteritis, 
or  there  is  merely  a  continuous  slight  frequency  of  stools,  which  may  for  a 
time  pass  almost  unnoticed  among  unintelligent  persons.  The  motions  are 
commonly  large,  pale,  soft,  and  pasty,  with  a  sour,  offensive  smell.  The 
child  gradually  grows  thin,  pale,  and  hollow-eyed.  There  is  clearly 
muscular  weakness.  There  is  but  little  evidence  of  pain,  and  the  abdomen 
becomes  distended.  The  appetite  is  capricious ;  it  may  be  voracious  from 
time  to  time,  but,  as  the  mother  remarks,  "  his  food  seems  to  do  him  no 
good."  The  appetite  finally  fails  altogether.  This  condition  is  essentially 
one  of  malnutrition  ;  and  if  it  proves  fatal,  as  often  happens,  death  occurs 
from  sheer  asthenia,  or  from  an  intercurrent  broncho-pneumonia  or 
pulmonary  collapse.  These  conditions,  grouped  under  the  name  of  catarrhal 
enteritis,  and  occurring  in  children  under  2  years  of  age,  must  always 
engage  the  closest  attention.  The  disease  may,  as  already  said,  rapidly 
yield  to  dieting.     It  may,  however,  under  the  most  favourable  conditions 


7o8  ALIMENTARY  SYSTEM. 

which  can  be  imposed,  either  continue  for  some  weeks  or  may  become 
chronic.  It  may  also  prove  rapidly  fatal,  or  the  child  may  die  at  a  much 
later  period  from  malnutrition.  In  any  case,  the  main  elements  in 
prognosis  are  the  age  of  the  child  and  the  previous  vital  condition.  It  is 
especially  fatal  to  children  who  are  weaned  at  an  early  period.  The  older 
the  child,  the  greater  is  the  resistant  power,  and  the  age  of  two  is  an 
important  stage  to  be  passed. 

Treatment. — It  happens,  though  but  seldom,  that  an  enteritis 
develops  in  a  child  which  is  being  brought  up  at  the  breast,  and  in  such 
cases  it  is  often  found  that  the  cause  lies  in  too  frequent  feeding  of  the 
child,  mothers  having  the  habit  of  giving  the  breast  in  order  to  quiet  the 
child.  In  such  cases  a  slight  purgative,  such  as  a  teaspoonful  of  castor-oil, 
or  two  teaspoonf  uls  of  the  castor-oil  mixture,  or  half  a  grain  of  grey  powder, 
twice  a  day,  with  directions  as  to  the  proper  method  of  suckling,  will  be  all 
that  is  necessary.  If  there  is  reason  to  believe  that  the  mother  is  supply- 
ing inferior  milk,  then  a  wet-nurse  must  be  employed  if  possible. 

In  many  cases,  however,  artificial  feeding  is  a  necessity.  If  it  be 
carried  out  with  care  and  intelligence,  the  fear  of  a  catarrhal  enteritis  is 
greatly  diminished.  The  two  main  objects  to  be  aimed  at  in  the  regulation 
of  artificial  feeding  of  infants  are — 1.  That  the  milk  should  approach  in 
character  as  near  as  may  be  to  that  of  the  mother.  2.  That  it  should  not 
have  undergone  any  degree  of  decomposition,  and  should  be  sterile  at  the 
time  of  use. 

Pure  cow's  milk  contains  more  proteids  and  more  fat,  but  rather  less 
carbohydrates,  than  human  milk,  its  casein  coagulates  in  large  masses, 
which  are  difficult  of  digestion,  and  it  is  in  consequence  unsuitable  food 
for  a  child.  Pure  goat's  milk  is  hardly  more  suitable,  for  the  same  reason. 
Ass's  milk,  on  the  other  hand,  of  which  the  casein  coagulates  in  fine 
flocculent  granules,  easy  of  digestion,  contains  so  small  a  percentage  of 
proteids  that  its  use  cannot  be  maintained  for  long.  Hence  cow's  milk 
must  be  used  in  the  majority  of  instances.  It  must  be  assimilated  to 
human  milk  by  dilution,  and  it  is  found  that  there  is  less  tendency  to  the 
massive  coagulation  of  the  casein  when  it  is  diluted  with  barley-water  or 
with  lime-water.  For  the  first  month  of  life  the  dilution  should  be  in  the 
proportion  of  one  part  of  milk  to  two  parts  of  barley-water,  with  the 
addition  of  a  little  sugar.  Of  this  mixture  25  to  30  oz.  is  sufficient.  The 
proportion  of  milk  in  the  mixture  may  be  gradually  increased,  and  from 
the  end  of  the  fourth  month  the  proportion  may  be  as  two  to  one,  and  2£ 
pints  may  be  given  in  the  day.  The  milk  should  always  be  boiled,  as 
boiling,  apart  from  other  advantages,  has  some  effect  in  preventing  massive 
coagulation  of  casein. 

Artificial  human  milk  may  also  be  obtained  as  a  commercial  article,  and 
may  be  found  useful.  The  simplest  plan  of  preparation  for  domestic  use 
is  that  of  Cheadle :  "  All  the  cream  is  removed  by  skimming  after  it  has 
stood  some  time ;  then  the  remainder  is  divided  into  two  equal  portions. 
From  one,  all  the  casein  is  removed  by  rennet,  that  is,  it  is  converted  into 
whey;  the  other  portion  is  then  mixed  with  the  whey,  and  the  whole 
of  the  cream  added.  As  the  child  grows  older  the  proteid  element 
should  be  increased  by  removing  the  curd  from  one-third  of  the  milk 
only,  instead  of  from  one-half  as  at  first."  Such  an  artificial  human  milk, 
however,  retains  the  disadvantage  arising  from  the  density  of  the  coagul- 
ated casein. 

The   second   object   to   be  kept  in  view  in  the  feeding  of  infants  is 


DISEASES  OF  THE  INTESTINES.  709 

cleanliness.  The  milk  must  be  as  fresh  as  possible ;  it  must  always  be 
boiled,  or  at  any  rate  sterilised,  and  the  bottle  and  all  its  parts  must  be 
kept  perfectly  clean. 

If  these  principles  be  observed  in  the  feeding  of  infants,  the  frequency 
of  a  catarrhal  enteritis  will  be  greatly  reduced,  and  a  return  to  these 
principles,  if  they  have  been  departed  from,  is  sometimes  the  only 
treatment  required.  The  removal  of  the  child  from  a  town  to  a  bracing 
country  air  is  an  important  preventive  measure,  and  it  is  equally 
important  during  convalescence. 

When,  however,  the  symptoms  are  more  severe,  additional  treat- 
ment and  a  special  diet  will  be  required.  All  milk  should  be  at  once 
forbidden,  and  proteid  material  must  be  given  in  other  forms.  The 
white  of  an  egg  stirred  up  in  half  a  pint  of  water,  with  a  few  drops  of 
brandy  and  a  little  salt,  is  a  good  article  of  diet.  Veal  or  chicken- 
broth  may  be  used.  Eaw-meat  juice  is  often  readily  taken.  It  may  be 
made  by  finely  mincing  some  beefsteak,  soaking  it  in  a  little  cold  water, 
and  then  expressing  the  juice,  either  with  a  lemon  squeezer,  or  by  forcibly 
twisting  it  in  muslin.  Of  this  2  or  3  oz.  may  be  given  in  twenty-four  hours. 
Eaw  meat  may  also  be  used  with  advantage  for  children  from  8  to 
12  months  old.  It  is  made  by  scraping  the  best  steak  into  a  pulp, 
pounding  in  a  mortar,  and  straining  through  a  fine  sieve ;  2  oz.  may  be  given 
in  twenty-four  hours,  and  it  is  well  to  add  to  it  and  to  the  meat  juice  a 
little  salt.  These  forms  of  food  may  be  combined  or  alternated  according  to 
circumstances.  Alcohol  is  often  necessary,  and  half  an  ounce  in  the  twenty- 
four  hours  may,  during  a  period  of  emergency,  be  safely  given  to  a  child  of  3 
months  old.  Barley-water  may  be  given  freely  for  thirst ;  whey  is  often 
useful,  and  is  well  taken,  and  if  there  is  any  sign  of  exhaustion,  it  is  a  good 
vehicle  for  the  administration  of  alcohol.  The  abdomen  and  extremities 
must  be  kept  warm,  and  if  the  temperature  is  high,  it  should  be  reduced 
by  tepid  bathing.  Food  must  be  given  in  small  quantities,  and  should  be 
cold  ;  it  may  be  given  at  intervals  of  two  hours.  If  the  child  is  seen  at  an 
early  period,  it  is  advisable  to  give  an  aperient  such  as  a  teaspoonful  of 
castor-oil,  or  two  teaspoonfuls  of  the  castor-oil  mixture.  For  this,  if  the 
vomiting  is  urgent,  a  powder  may  be  substituted,  containing  -3  gr.  of 
powdered  rhubarb  and  2  gr.  of  bicarbonate  of  soda ;  and  this  may  be 
followed  with  advantage,  in  cases  where  the  diarrhoea  is  not  very  severe,  by 
half  a  grain  of  mercury  and  chalk,  with  half  a  grain  of  Dover's  powder,  given 
twice  a  day  for  two  or  three  days,  in  the  case  of  a  child  of  6  months  old 
and  upwards. 

If  the  diarrhoea  is  more  urgent,  and  the  drain  of  fluid  and  risk 
of  exhaustion  is  great,  it  must  be  dealt  with  energetically  by  the  use 
of  subnitrate  of  bismuth,  Dover's  powder,  and  aromatic  chalk  powder.  If 
the  vomiting  is  persistent,  powders  are  preferable  to  liquid  medicine.  Five 
gr.  of  subnitrate  of  bismuth  with  a  quarter  of  a  grain  of  Dover's  powder, 
and  3  gr.  of  aromatic  chalk  powder,  may  be  given  every  four  hours  to  a  child 
6  months  old.  In  a  fluid  mixture  containing  the  same  amount  of  bismuth, 
half  a  minim  of  tincture  of  opium  may  be  used.  The  dose  of  Dover's 
powder  and  of  tincture  of  opium  may  be  doubled  for  a  child  of  1  year. 
In  some  of  these  cases,  at  any  rate,  especially  those  occurring  in  hot 
weather,  there  is  distinct  indication  for  the  use  of  some  intestinal  dis- 
infectant. It  is,  however,  by  no  means  clear  that  any  of  the  drugs  which 
can  be  used  for  this  purpose,  such  as  |3-naphthol,  resorcin,  perchloride  of 
mercury,  salol,  etc.,  can  be  trusted  to  give  a  better  result  than  the  bismuth 


7io  ALIMENTARY  SYSTEM. 

mixture  above  mentioned.  Three  gr.  of  salicylate  of  soda  or  one-eighth  of 
a  grain  of  calomel,  may  however,  be  given  with  the  bismuth  every  four 
hours  to  a  child  1  year  old,  or  a  powder  containing  3  gr.  of  salicylate  of 
bismuth  with  2  gr.  of  salol  may  be  used  with  advantage.  When  the 
process  of  exhaustion  is  proceeding  apace,  infusion  with  normal  saline 
solution  is  of  great  service,  as  in  the  choleraic  form  of  diarrhoea,  which  is 
subsequently  described. 

In  chronic  cases  the  same  lines  of  dietetic  and  medicinal  treatment 
must  be  observed.  There  must  be  great  caution  in  the  return  to  a  milk 
diet,  and  quinine  and  acid  tonics  will  be  useful  during  convalescence. 

Cholera  Nostras. 

This  is  an  acute  disease,  occurring  in  temperate  climates,  which 
has  a  close  resemblance  to  Asiatic  cholera,  but  differs  from  it  in  being 
of  sporadic,  not  endemic,  occurrence,  and  in  being  milder  and  far  more 
favourable,  at  any  rate  in  adults.  It  is  common  enough  in  the  adult ; 
but  is  especially  apt  to  attack  children,  and  in  them  has  a  high  rate  of 
mortality.  It  is  almost  confined  in  its  occurrence  to  the  hot  months  of  the 
year,  and  becomes  most  common  when  heat  and  drought  are  combined. 
It  has  been  shown  that  it  is  particularly  apt  to  occur  when  the 
temperature  of  the  earth  at  a  depth  of  1  foot  reaches  62°  F. 
(Tomkins.)  In  some  cases,  especially  in  adults,  there  is  a  history  of  having 
eaten  some  article  which  is  prone  to  decomposition,  such  as  sausage-meat, 
and  shellfish,  but  in  many  instances  no  such  history  is  forthcoming. 

Morbid  anatomy.  —  The  rapid  development  of  such  severe 
symptoms,  the  absence  of  evidence  of  gross  structural  disease  in  the  in- 
testine, and  the  close  resemblance  to  Asiatic  cholera,  point  strongly  to  the 
cause  as  being  the  absorption  of  some  poison  of  bacterial  origin  from  the 
alimentary  canal,  either  taken  in  from  without,  or  more  probably  produced 
there  by  bacterial  action.  The  spirillum  of  Finkler  and  Prior,  which  has 
been  advanced  as  the  cause,  is  now  discredited.  No  specific  organism  is 
known ;  and  the  evidence  at  present  to  hand  points  rather  to  the  agency 
of  some  one  or  more  species  of  common  putrefactive  organism,  such  as 
Proteus  vulgaris  and  certain  allied  forms.  Post-mortem  changes  are  ex- 
ceedingly slight.  The  stomach  and  intestines  are  usually  empty  and  pale. 
There  may  be  patches  of  hyperemia  in  the  small  bowel,  and  occasionally 
punctiform  hemorrhages  may  be  seen  in  the  mucous  membrane. 

Symptoms. — The  patient  is  suddenly  seized  with  vomiting  and 
diarrhoea.  After  the  preliminary  rejection  of  the  contents  of  the  stomach, 
copious  vomiting  of  fluid  continues,  which  is  to  a  less  and  less  extent  tinged 
with  bile.  The  motions  are  similarly  at  first  bile-stained ;  but  they  be- 
come more  and  more  colourless,  and  may  reach  the  rice-water  condition  of 
Asiatic  cholera.  They  are  often  exceedingly  profuse ;  there  may  be  a  large 
outpouring  of  fluid  every  hour,  with  pain  and  griping.  Sometimes  the 
abdominal  pain  is  very  slight.  There  is  always  great  thirst,  and  there  may 
be  severe  cramps  in  the  muscles  of  the  linibs,  especially  in  the  calves.  The 
collapse  is  rapid  and  alarming,  the  pulse  becomes  quick  and  feeble,  and  the 
temperature  is  subnormal.  The  eyes  are  sunken,  the  extremities  feel  cold 
and  have  a  bluish  tint ;  the  skin  of  the  fingers  becomes  wrinkled,  as  if  the 
tissues  were  shrunken.  The  urine  is  scanty  or  entirely  suppressed.  In  this 
condition  the  patient  may  remain  for  twenty-four  or  thirty-six  hours,  and 
it  is  in  this  stage  that  death,  if  it  occurs  at  all,  supervenes.     If  this  stage  is 


DISEASES  OF  THE  INTESTINES.  711 

survived  there  is  little  further  danger  to  be  apprehended.  The  vomiting 
and  diarrhoea  subside,  the  collapse  passes  off',  and  the  recovery  is  strikingly 
rapid,  considering  the  extremity  of  the  illness  so  quickly  reached,  and  it  is 
usually  complete  in  three  or  four  days.  Not  all  cases  are  so  severe  as  in 
the  example  here  given.  Milder  forms  occur,  and  in  this  direction  the 
disease  shades  off  into  the  severer  forms  of  catarrhal  enteritis  previously 
described,  and  no  accurate  line  of  demarcation  is  possible.  The  stools  in 
all  cases  should  be  examined  with  a  view  to  determining  the  presence 
or  absence  of  comma  bacilli ;  but  expert  knowledge  is  required  for  the 
purpose.  A  fatal  event  is  by  no  means  common.  It  is  more  likely  to 
occur  in  the  old  or  feeble,  or  in  those  debilitated  by  alcohol  or  previous 
disease  ;  but  it  may  undoubtedly  prove  fatal  even  in  the  physically  strong 
and  healthy.  In  children,  however,  it  is  attended  with  a  high  rate  of 
mortality. 

Treatment. — The  administration  of  drugs  by  the  mouth  or  by  the 
rectum  in  the  early  stage  is  difficult  or  impossible,  owing  to  the  incessant 
vomiting  and  diarrhoea.  And  the  subcutaneous  injection  of  morphine,  freely 
but  carefully  used,  is  often  the  only  remedy,  and  even  this  must  be  discon- 
tinued if  the  patient  becomes  collapsed  and  the  urinary  secretion  much  dimin- 
nished.  If  the  vomiting  is  not  very  urgent,  salicylate  of  bismuth  and  salol 
with  Dover's  powder  or  tincture  of  opium  may  be  administered  from  the  first. 
Iced  brandy  and  water  may  be  given  in  small  quantities,  and  some  may  be 
absorbed  even  in  severe  cases,  or  iced  milk  or  barley-water  with  brandy  or 
whisky  in  it.  Hot  fomentations,  with  or  without  mustard  to  the  abdomen, 
undoubtedly  give  relief.  If  the  collapse  is  severe,  the  patient  must  be 
infused  with  normal  saline  solution,  and  four  or  five  pints  at  least  may  be 
allowed  to  run  into  a  vein  in  the  arm,  with  a  marvellous  effect  upon  the 
condition  and  appearance  of  the  patient.  Inasmuch  as  the  period  of 
collapse  is  a  short  one,  one  infusion  may  prove  sufficient ;  but  it  may 
always  be  safely  repeated,  though  the  success  attending  second  and  subse- 
quent infusion  is  much  less  marked  than  that  of  the  first.  Large  enemata 
of  water,  given  by  gravity,  up  to  two  or  three  pints,  will  certainly  prove  of 
service,  but  a  profuse  diarrhoea  will  hinder  their  use.  As  soon  as  the 
diarrhoea  and  vomiting  begin  to  abate,  there  is  little  cause  for  further 
anxiety;  and  the  feeding  may  be  steadily  increased  on  general  principles 
without  fear  of  relapse. 

Choleea  Infantum. 

We  have  here  to  deal  with  an  affection  which  is  probably  identical 
with  the  cholera  nostras  already  described.  It  is  common  among  children 
in  large  towns  during  the  hot  months  of  the  year,  and  it  annually  claims 
so  large  a  number  of  victims  that  it  merits  some  separate  description.  As 
regards  its  causation  and  nature  nothing  need  be  added.  That  its 
symptoms  are  dependent  on  the  absorption  of  a  bacterial  poison,  and  not 
upon  any  gross  intestinal  change,  is  rendered  probable  by  the  evidence 
already  given  as  regards  cholera  nostras,  and  it  must  be  admitted  that  no 
absolute  line  of  demarcation  can  be  drawn  upon  clinical  grounds  between 
it  and  the  more  severe  form  of  catarrhal  enteritis  already  described. 

Morbid  anatomy. — The  absence  of  post-mortem  changes  after  such 
a  rapid  and  violent  death  as  may  occur  is  very  striking.  The  intestines 
are  pale  and  shrunken  and  translucent,  and  seldom  show  any  hyperemia, 
or  at  most  patches  of  injected  vessels  which  are  not  improbably  a  post- 


712  ALIMENTARY  SYSTEM. 

mortem  phenomenon.  "No  change,  or  at  most  only  a  little  swelling,  is  to 
be  observed  in  the  lymphatic  structures.  All  the  tissues,  especially  the 
serous  membranes,  are  unusually  dry,  and  the  organs  are  very  pale. 

Symptoms. — The  illness  has  commonly  a  rapid  and  violent  onset. 
The  child  is  seized  with  vomiting  and  diarrhoea,  both  of  which  become 
violent  and  incessant.  The  vomit  becomes  a  watery  bile-tinged  fluid. 
The  stools  soon  lose  all  trace  of  fecal  matter,  and  have  but  little  smell. 
They  consist  of  a  thin  serous  fluid,  which  may  be  colourless  or  but  little 
tinged  with  bile.  A  stool  may  be  passed  every  hour.  There  is  usually 
great  restlessness  at  first,  and  probably  also  pain  and  aching  in  the  limbs. 
The  child's  thirst  is  distressing,  and  it  cannot  be  appeased,  owing  to  the 
vomiting.  There  is  a  rapid  alteration  in  the  child's  appearance.  In  a 
few  hours  the  eyes  may  be  sunken,  the  face  deadly  pale,  with  cheeks 
fallen  in,  and  features  sharpened.  The  fontanelle  becomes  depressed,  the 
abdomen  shrunken  and  flaccid,  the  tongue  dry,  the  pulse  small,  frequent, 
running,  and  uncountable.  The  temperature  in  the  axilla  at  any  rate 
is  usually  subnormal,  and  may  fall  to  96°  or  lower  before  death,  but  the 
rectal  temperature  is  often  found  to  be  raised,  and  may  reach  104°.  The 
urine  is  necessarily  scanty,  or  is  completely  suppressed.  In  cases  that  are 
going  to  prove  fatal,  the  restlessness  passes  into  apathy,  drowsiness,  and 
apparent  peace.  Sometimes  convulsions  end  the  scene.  Some  cases,  of 
course,  end  favourably,  but  death  is  the  more  common  ending,  and  it  may 
occur  in  the  first  day  of  the  illness,  or  life  may  be  prolonged  for  three  or 
four  days. 

Treatment. — The  disease  must  be  combated  energetically  from  the 
first,  if  the  child  is  to  have  a  chance  of  living ;  but  as  in  Asiatic  cholera,  so 
here,  the  administration  of  any  food  or  medicine  by  mouth  or  rectum  is 
difficult  or  impossible. 

As  regards  feeding,  in  severe  cases  it  is  impossible  to  administer 
nutriment.  When,  however,  the  vomiting  is  less  urgent,  persistent  efforts 
should  be  made  to  introduce  nutriment  into  the  stomach.  Milk  is  out  of 
the  question.  Small  quantities  of  whey  with  alcohol  or  iced  champagne,  or 
raw-meat  juice  give  the  best  chance,  and  plenty  of  iced  barley-water  may 
be  allowed,  or  water  containing  the  whites  of  two  eggs,  and  1  oz.  of  brandy 
to  the  pint  may  be  used.  An  attempt  may  be  made  also  to  administer 
alcohol  and  strong  beef -tea  by  the  rectum,  and  possibly  some  may  be  ab- 
sorbed between  the  stools.  Hot  baths  are  of  decided  use,  containing  1  oz. 
of  mustard  to  the  gallon.  Injections  of  brandy  under  the  skin  are  of  use  in 
tiding  over  the  acute  period,  and  there  is  no  doubt  as  to  the  value  of 
large  intravenous  infusion  of  saline  fluid,  though  the  good  effect  is  but  of 
short  duration,  and  can  hardly  be  attained  by  its  repetition.  As  regards 
drugs,  morphine  subcutaneously  stands  in  the  front  rank.  A  child  of  one 
year  old  may  safely  have  one-fiftieth  or  one-thirtieth  of  a  grain  at  intervals 
of  two  hours,  but  as  regards  the  numerous  other  drugs,  the  so-called 
intestinal  disinfectants,  such  as  salol,  perchloride  of  mercury,  resorcin,  etc., 
the  incessant  vomiting  as  a  rule  will  not  admit  their  use.  Large  rectal 
injections  of  iced  water  have  been  found  of  service.  If  the  symptoms 
show  signs  of  subsiding,  the  field  for  food  and  drugs  is  wider.  Still  keep- 
ing to  alcohol,  beef -juice,  whey,  or  brandy-and-egg  mixture,  opium  (as  the 
tincture  or  as  Dover's  powder)  may  be  administered  by  the  mouth.  And 
as  recovery  ensues,  the  feeding  must  be  carefully  increased,  but  milk  must 
be  withheld  until  some  time  after  all  danger  is  over.  If  the  fever  is  high, 
baths  may  be  used,  but  this  is  seldom  an  urgent  symptom.     It  must  be 


DISEASES  OF  THE  INTESTINES.  713 

remembered  iu  the  treatment  that  it  must  be  assiduous  and  energetic  from 
the  very  first,  and  that  attention  must  be  more  particularly  directed  to 
preserving  strength  for  the  three  or  four  days  of  danger. 

Ceoupous  or  Diphtheritic  Enteritis. 

An  inflammatory  disease  of  the  bowel,  which  is  characterised  by 
some  degree  of  necrosis  of  the  mucous  membrane,  and  by  the  forma- 
tion of  a  pellicle  consisting  of  coagulated  exudation.  The  old-fashioned 
term  diphtheritic  has  reference  merely  to  the  formation  of  a  membrane 
as  characterising  the  disease,  and  it  does  not  imply  any  theory  as  to  its 
origin. 

Etiology. — The  actual  origin  of  this  form  of  enteritis  is  unknown.  It 
is  occasionally  found  unexpectedly  in  the  post-mortem  room,  after  death 
from  severe  bacterial  or  chronic  diseases,  more  especially  pneumonia, 
pyaemia,  typhoid  fever,  cirrhosis  of  the  liver,  and  Bright's  disease.  It  may 
be  set  up  by  the  action  of  certain  poisons,  such  as  mercury,  arsenic, 
and  lead.  It  also  occurs,  though  rarely,  as  a  primary  disorder  of  the  bowel, 
independent  of  disease  elsewhere. 

Morbid  anatomy.  —  The  main  changes  are  a  necrosis  of  the 
mucous  membrane  and  the  formation  of  a  membrane  on  the  necrosed 
area,  which  consists  of  coagulated  inflammatory  exudation.  The  necrosis 
may  be  superficial,  or  it  may  involve  the  whole  thickness  of  the  mucosa. 
The  grey  patches  thus  formed  are  found  at  any  part  of  the  intestine, 
large  or  small.  They  are  apt  to  occur  on  prominent  points  of  the  mucous 
membrane,  such  as  the  valvulae  conniventes  or  the  intersaccular  ridges  of 
the  colon.  Sometimes  the  solitary  follicles  are  more  particularly  affected. 
Sometimes  a  few  large  patches  are  found,  and  in  the  case  which  is  men- 
tioned below  as  being  of  primary  occurrence  one  large  patch  4  in.  by 
2  in.  occupied  the  sigmoid  flexure,  the  rest  of  the  intestine  being 
healthy.  There  is  usually  some  affection  of  the  rest  of  the  bowel  wall 
at  the  affected  point.  The  membranous  patch  is  surrounded  by  a  zone  of 
hyperemia,  the  submucosa  and  muscular  coats  are  swollen  and  cedematous, 
and  sometimes  the  whole  thickness  of  the  wall  has  been  found  in  the 
post-mortem  room  to  be  gangrenous  or  of  doubtful  vitality.  It  is  probable, 
from  the  analogy  of  membranes  of  similar  structure  elsewhere,  that  the 
immediate  origin  of  the  croupous  inflammation  is  to  be  sought  for  in 
bacterial  agency. 

Symptoms. — No  detailed  account  of  the  symptoms  of  this  condition 
can  be  given.  It  is  sufficient  to  say  that  it  is  most  commonly  marked 
by  profuse  diarrhoea,  which  is  scarcely  controlled  by  any  drugs,  and 
occasionally  by  the  passage  of  blood.  Pain  is  commonly  absent.  It  arises 
for  the  most  part,  as  has  been  already  said,  in  a  late  stage  of  other 
diseases,  so  that  any .  special  characters  it  may  have  are  necessarily 
obscured. 

On  the  other  hand,  the  primary  form  of  the  disease  may  bear  a 
close  resemblance  to  intestinal  obstruction  or  peritonitis.  There  is  com- 
plete constipation,  though  flatus  may  be  passed.  The  vomiting  is  severe, 
the  tongue  becomes  dry,  the  pulse  rapid,  and  the  abdomen  becomes 
distended  and  often  tender.  The  constipation  is  presumably  due  to 
the  paralysis  of  a  large  section  of  the  bowel.  In  one  such  case  the 
patient  was  seized  with  violent  abdominal  pain,  vomiting,  and  rapid 
collapse,    which    suggested    an    intestinal    obstruction,    and     abdominal 


714  ALIMENTARY  SYSTEM. 

exploration  was  carried  out  on  that  supposition.     Death  occurred  within 
forty-eight  hours  of  the  apparent  onset. 

Treatment. — The  treatment  in  the  commoner  form  of  the  disease 
must  be  by  drugs  such  as  have  been  already  recommended  in  the  case 
of  the  chronic  catarrhal  form  of  enteritis,  which  arises  under  somewhat 
similar  conditions ;  and  if  the  general  condition  of  the  patient  permits 
it,  an  attempt  may  be  made  to  control  the  diarrhoea  by  large  astringent 
injections  of  alum,  sulphate  of  copper,  or  nitrate  of  silver. 

Phlegmonous  Entekitis. 

This  condition  is  rarely  if  ever  a  primary  occurrence.  It  results 
usually  from  some  severe  mechanical  damage  to  the  bowel,  such  as  may  be 
caused  by  an  intussusception,  by  strangulation  of  the  bowel  in  the 
abdominal  cavity  or  in  the  hernial  apertures,  and  by  the  impaction  of  a 
gallstone.  All  the  coats  of  the  bowel  are  implicated  at  the  damaged  spot. 
The  peritoneal  surface  is  dark  red  or  purple,  or  even  black.  Its  polish 
may  be  lost,  and  it  may  be  sticky,  or  roughened  by  a  deposit  of  coagulated 
inflammatory  exudation  upon  it.  The  other  coats  are  swollen  and  soft, 
owing  to  their  congestion  and  oedema,  and  in  some  cases  they  become 
gangrenous.  The  condition  is  very  severe.  Pain,  vomiting,  complete 
inaction  of  the  bowels,  abdominal  distension  with  fever  and  collapse,  are 
the  salient  features.  The  symptoms  closely  resemble  those  of  peritonitis, 
and  indeed  some  degree  of  peritonitis  is  commonly  associated.  The 
medical  treatment  must  be  such  as  is  laid  down  for  peritonitis,  but  it  is 
commonly  of  little  avail,  and  the  resources  of  surgery,  if  timely,  may  afford 
some  hope. 

Mucous  Colitis* 

An  affection  which  is  probably  limited  to  the  large  intestine,  and  Is 
characterised  clinically  by  the  passage  of  much  mucus  in  the  stools. 
The  mucus  often  occurs  in  the  form  of  membranous  casts  of  the  bowels 
(enterite  muco-membraneuse),  but  the  disease  must  be  carefully  distinguished 
from  the  croupous  or  diphtheritic  enteritis  already  described. 

Etiology. — Our  knowledge  of  its  causation  is  scanty.  It  occurs  most 
commonly  in  adults  between  the  ages  of  20  and  40,  but  is  occasionally 
met  with  outside  these  limits.  It  is  far  more  common  in  women  than 
in  men,  the  proportion  being  roughly  as  four  to  one.  Both  the  men  and 
the  women  who  are  affected  seem  to  be  of  a  peculiar  temperament ;  they 
are  nervous,  excitable,  and  unstable,  with  a  tendency  to  neurasthenia.  In 
late  stages  they  often  become  hypochondriacal  and  even  melancholic.  The 
neurasthenic  tendency  seems  to  be  a  constant  and  early  accompaniment, 
and  to  this  extent  heredity  plays  some  part.  It  is  almost  invariably 
accompanied  by  chronic  constipation,  but  this  can  hardly  be  taken  to  have 
a  very  close  connection  with  its  origin,  if  the  relative  frequency  of  the  two 
conditions  is  compared.  There  is  no  evidence  pointing  to  any  bacterial 
agency.  It  has  often  been  noted  to  occur  in  association  with  disease  of 
the  vermiform  appendix. 

Morbid  anatomy. — Nothing  certain  is  known  as  to  the  pathology 
of  the  disease.  An  inflammatory  process  in  the  bowel  wall  has  been 
described,  but,  considering  the  long  duration  of  the  disease,  it  is  improbable 
that  there  is  any  gross  structural  change  in  the  majority  of  cases.  The 
membrane  has  indeed  been  seen  in  situ,  closely  adherent  in  the  colon,  and 


DISEASES  OF  THE  INTESTINES.  715 

it  was  capable  of  separation  without  any  lesion  of  the  surface  (Osier).  It 
is  possible  that  it  is  essentially  a  disturbance  of  secretion,  independent  of 
any  inflammatory  process,  and  in  suppoit  of  this  view  it  should  be  noted 
that  the  disease  is  almost  confined  to  the  neurasthenic  stock,  and  that 
the  amount  of  mucus  produced  is  far  greater  than  in  any  known  form  of 
definite  inflammation  of  the  bowel. 

Symptoms. — It  is  not  a  common  affection  in  this  country,  but  it 
seems  to  occur  more  commonly  in  private  than  in  hospital  practice.  In 
well-marked  cases  the  disease  runs  a  course  of  many  years.  There  are 
definite  attacks  of  abdominal  pain  with  the  passage  of  mucus,  and  between 
the  attacks  the  patient  may  enjoy  fair  health  although  usually  constipated. 
The  attacks  last  for  a  week  or  more,  and  they  recur  at  variable  intervals. 
Sometimes  a  succession  of  attacks  may  occur  with  hardly  any  interval, 
sometimes  there  are  only  two  or  three  in  a  year.  The  pain  is  of  a  colicky 
griping  nature,  and  may  be  severe.  It  may  be  referred  by  the  patient  to 
either  side  of  the  abdomen,  and  is  often  referred  to  one  or  other  of  the 
iliac  fossse.  There  is  usually  a  general  feeling  of  illness;  there  is  sometimes 
nausea,  and  occasionally  vomiting.  The  temperature  is  rarely  if  ever 
raised.  The  abdomen  is  often  somewhat  distended,  and  it  presents  some 
tenderness  on  palpation  in  some  part  of  the  course  of  the  large  intestine. 
After  one  or  more  days  spent  in  this  condition,  during  which  the  patient 
is  commonly  confined  to  bed,  the  constipation  yields  to  some  extent,  and 
with  every  stool  there  is  passed  a  notable  quantity  of  mucus.  The  mucus 
may  appear  in  flakes,  round  masses,  or  strings,  but  it  often  forms  a 
complete  cast  of  the  bowel  from  an  inch  to  a  foot  in  length.  These  casts, 
of  which  the  tubular  character  is  seen,  if  they  are  unfolded  under  water, 
are  tough  and  somewhat  translucent,  and  may  be  one-eighth  of  an  inch  in 
thickness.  Chemically  they  may  be  shown  to  consist  of  mucus,  but  they 
contain  also  degenerate  epithelial  cells,  fa?cal  particles,  and  phosphatic 
crystals.  No  fibrin  enters  into  their  structure,  but  they  may  contain  a 
small  quantity  of  some  proteid  substance.  Barely  they  have  been  seen 
to  be  streaked  with  blood.  Mucus  in  one  or  other  form  may  thus 
be  passed  once  or  several  times  a  day  for  several  days,  when  it  dis- 
appears. The  pain  then  subsides,  and  the  patient  returns  to  comparative 
health. 

During  the  intervals,  however,  constipation  is  always  troublesome. 
The  patient  is,  moreover,  apprehensive  of  the  next  attack.  She  is  dys- 
peptic, anaemic,  and  ill-nourished.  There  is  a  tendency  to  depression,  with 
loss  of  energy  and  loss  of  interest  in  surroundings,  but  this  mental  condi- 
tion seems  rarely  to  pass  the  boundary  line  into  actual  melancholia. 

Not  all  instances  have  so  sharp  an  outline  as  this,  though  the  general 
characters  described  above  can  always  be  recognised.  Sometimes  the 
habitual  constipation  is  the  salient  feature,  and  the  attacks  of  mucus- 
passing  and  pain  may  be  ill-defined  and  may  pass  unrecognised.  On  the 
other  hand,  exceptional  cases  have  been  recorded,  in  which  the  attacks 
have  been  severe  and  continuous,  and  mucus  has  been  passed  in  great 
abundance  with  diarrhcea,  and  a  fatal  event  has  occurred  apparently  through 
sheer  exhaustion.  It  should  be  noted  that  the  paroxysmal  attacks  may 
bear  some  resemblance  to  attacks  of  local  peritonitis  arising  round  a 
diseased  appendix,  especially  when  the  pain  and  tenderness  are  limited  to 
the  right  iliac  fossa.  The  distinction  between  the  two  conditions  can  be 
readily  made  at  the  time  of  the  attack,  by  the  absence  of  fever  and  of  any 
definite  sign   of  peritonitis,  but  the  differential  diagnosis  may  be  very 


7 1 6  ALIMENTAR  Y  SYSTEM. 

difficult  in  the  interval,  when  an  actual  attack  has  not  been  closely 
observed,  and  it  can  be  made  only  by  a  careful  sifting  of  the  history. 

The  duration  of  the  disease  cannot  be  stated  with  accuracy.  It  cer- 
tainly may  disappear,  though  this  result  can  be  hardly  attributed  to  any 
particular  course  of  treatment.  But  more  commonly  it  continues  un- 
checked for  many  years. 

Treatment. — In  the  present  state  of  our  knowledge  the  treatment  of 
this  disorder  can  only  be  tentative.  For  the  general  condition,  especially 
if  there  is  wasting,  a  course  of  general  massage  may  be  found  to  be  of  some 
use,  and  arsenic  or  strychnia  may  be  administered  at  the  same  time.  Irun 
can  hardly  be  used  without  increasing  the  constipation.  Salicylate  of 
bismuth  or  salol,  or  both,  are  often  used  and  may  have  some  effect  in 
diminishing  the  frequency  of  the  attacks.  The  diet  must  be  simple  and 
plentiful,  but  there  is  no  reason  for  choosing  one  form  of  food  more  than 
another.  The  life  must  be  as  regular  and  healthy  as  circumstances  allow, 
and  the  surroundings  should  be  bright  and  cheerful.  The  constipation 
must  be  treated  on  general  principles,  such  as  are  laid  down  elsewhere, 
and  strong  purgatives  are  to  be  avoided. 

During  an  attack  the  pain  must  be  relieved  as  far  as  possible  by 
hot  fomentations  and  counter-irritants.  Morphine  should  never  be  used, 
as  all  the  conditions  are  present  which  favour  the  development  of  a 
morphine  habit.  Cannabis  indica  has  been  recommended  as  a  substitute. 
The  diet  should  be  limited  to  milk.  The  castor-oil  mixture  is  of  use  in 
aiding  the  expulsion  of  the  mucus,  and  large  injections  of  warm  boracic 
acid  solution,  gently  administered  by  gravity,  may  possibly  be  of  service. 
No  specific  cure  is  known,  and  cases  are  rare  in  which  any  improve- 
ment can  be  truly  attributed  to  any  particular  method  of  treatment. 

It  has  been  suggested  that  in  severe  cases,  where  the  patient  is 
showjng  signs  of  exhaustion,  owing  to  a  continuance  of  painful  attacks, 
it  may  be  justifiable  to  make  an  artificial  anus  into  the  ascending  colon, 
with  the  double  object  of  affording  rest  to  the  lower  bowel  and  of  being 
enabled  to  flush  it  out  thoroughly  from  above.  A  case  of  this  kind  under 
the  care  of  Hale  White  was  followed  bv  a  fair  measure  of  success. 

Ulcerative  Colitis. 

This  name  is  given  to  an  ulceration  of  the  colon,  which  occurs  in 
temperate  climates.  The  naked -eye  characters  of  the  bowel  closely 
resemble  those  of  dysentery,  but  the  clinical  features  of  the  two  condi- 
tions present  some  points  of  difference. 

Etiology. — No  specific  cause  is  known,  and  no  connection  has  as 
yet  been  traced  with  any  protozoon  or  microbe.  It  has  no  apparent 
relation  with  locality,  season,  or  climatic  condition.  It  occurs  in  both 
sexes,  perhaps  rather  more  commonly  in  women  than  men,  and  attacks 
adults  of  any  age.  There  is  some  evidence  as  to  a  late  association  with 
chronic  interstitial  nephritis  and  gout. 

Morbid  anatomy. — The  appearance  of  the  colon  after  death  is  much 
the  same  as  in  dysentery.  The  ulceration  may  be  found  in  the  whole 
length  of  the  large  bowel,  or  it  may  be  limited  to  a  portion  of  it,  a  foot 
or  so  in  length,  or  it  may  occur  in  separate  patches.  Usually  there  has 
been  great  destruction  of  the  mucosa  and  submucosa,  so  that  the  muscular 
coat  is  laid  bare  in  the  floor  of  large  ulcers.  The  ulcers  are  of  various  sizes 
and   shapes,   sometimes   separate,   sometimes    confluent.      The    surviving 


DISEASES  OF  THE  INTESTINES.  717 

mucous  membrane  is  represented  by  islands  of  cedematous  tissue,  which 
are  often  undermined  at  their  bases,  and  are  therefore  polypoidal  in  shape. 
Strands  of  surviving  mucous  membrane  may  also  be  seen,  which  are 
completely  undermined  and  left  as  bridges  over  an  ulcer.  If  larger  tracts 
of  mucous  membrane  remain,  there  may  be  seen  small  orifices  in  it, 
which  have  given  exit  to  inflammatory  products  from  below.  A  similar 
appearance  is  seen  in  amoebic  dysentery  (Councilman  and  Lafleur).  And 
these  appearances  may  perhaps  be  taken  as  indicating  that  the  deeper 
part  of  the  mucosa  or  the  submucosa  is  the  starting-point  of  the  morbid 
change. 

Symptoms.  —  The  chief  feature  of  the  disease  is  an  intractable 
diarrhoea.  The  bowels  are  moved  at  least  three  or  four  times  in  the 
day,  sometimes  much  more  frequently.  The  motions  commonly  consist 
of  a  little  fsecal  matter  unformed,  with  dark  offensive  fluid,  and  they  often 
contain  blood.  Sometimes  in  later  stages  the  haemorrhage  may  be  severe, 
and  it  has  been  known  to  be  the  immediate  cause  of  death.  Mucus  is  not 
present,  except  perhaps  in  an  early  stage.  There  is  seldom  any  severe 
rectal  pain  or  tenesmus,  but  there  is  often  considerable  general  pain  in  the 
abdomen,  both  during  defalcation  and  at  other  times.  Sometimes,  how- 
ever, it  is  slight  and  unimportant.  Vomiting  is  uncommon.  The  tongue  is 
pale  and  furred,  and  may  become  dry.  The  temperature  may  be  normal 
throughout,  but  there  is  sometimes  a  moderate  degree  of  pyrexia,  and 
an  evening  record  of  104°  is  occasionally  reached.  The  abdomen  may 
be  flaccid  or  slightly  distended,  and,  owing  to  the  thinness  of  its  wall, 
the  peristaltic  movements  of  the  intestine  may  sometimes  be  seen.  The 
patient  wastes  rapidly,  and  an  extreme  degree  of  emaciation  may  be 
reached,  if  life  be  prolonged.  Hepatic  abscess  may  conceivably  occur,  as  in 
any  ulcerative  condition  of  the  bowel,  but  it  is  very  rare.  Death  commonly 
occurs  from  exhaustion,  but  sometimes  by  perforation  and  peritonitis.  The 
duration  of  the  acute  disease  is  seldom  more  than  two  months,  and  it  is 
almost  invariably  fatal.  In  some  instances,  however,  it  has  been  known  to 
undergo  temporary  abatement  from  time  to  time,  so  that  it  has  extended 
over  a>  year  or  more,  but  it  is  doubtful  whether  permanent  recovery 
ever  occurs. 

Treatment. — No  specific  cure  is  known.  The  treatment  is  much  the 
same  as  is  suggested  for  a  chronic  dysentery.  Absolute  rest,  with  a  milk 
diet,  must  be  obtained.  Bismuth  and  opium  will  probably  afford  as  much 
relief  as  can  be  expected  in  so  severe  a  condition,  and  the  propriety  of 
making  an  artificial  anus  in  the  ascending  colon,  in  cases  which  are  not  too 
far  advanced,  must  always  receive  consideration. 


INTESTINAL  OBSTEUCTION. 

The  conditions  here  described  will  be  seen  to  arise  from  widely 
different  causes,  but  they  have  one  common  feature,  in  that  they  all 
produce  some  mechanical  impediment  to  the  passage  of  the  intestinal 
contents.  In  many  of  these  conditions  some  damage  is  inflicted  upon 
the  bowel  wall  at  the  same  time.  The  combined  symptoms,  which  result 
from  the  mechanical  impediment  and  from  the  damage  to  the  bowel, 
vary  from  those  of  a  mere  chronic  constipation  to  those  of  an  acute 
attack,  terminating  fatally  in  a  few  days.  These  conditions  are  commonly 
arranged  under  the  following  heads : — (1)  Strangulation  by  bands  or  through 


718  ALIMENTARY  SYSTEM. 

apertures,  (2)  stricture,  (3)  volvulus,  (4)  compression  and  traction  by 
adhesions,  (5)  intussusception,  and  (6)  blocking  by  foreign  bodies. 

Etiology  and  pathology. — Strangulation  by  bands  or  through 
apertures. — This  is  the  most  common  form,  and  roughly  one- third  of  all 
cases  of  intestinal  obstruction  fall  under  this  head.  The  type  of  the  group 
is  the  strangulated  hernia,  which  is  dealt  with  in  surgical  text-books. 
The  mechanism  of  strangulation  of  the  bowel  is  the  same  in  all  instances. 
It  may  be  broadly  stated  that  a  loop  of  the  bowel,  usually  the  small 
bowel,  is  thrust  by  some  sudden  movement  through  an  aperture,  which  is 
sufficiently  narrow  or  tight  to  obstruct  the  venous  flow  from  the  portion 
engaged.  The  swelling  of  the  loop,  which  immediately  ensues  from  the 
venous  engorgement,  hinders  its  return,  and  in  nearly  all  cases  its  release 
quickly  becomes  improbable,  save  by  surgical  aid.  The  bowel  is  then  said 
to  be  strangulated.  The  interference  with  the  blood  supply  of  the  affected 
part  may  be  so  extreme  as  to  lead  to  gangrene. 

The  aperture  is  in  most  cases  formed  by  the  stretching  of  a  band 
in  some  part  of  the  abdomen,  either  from  bowel  to  bowel,  or .  more  com- 
monly from  bowel  to  some  part  of  the  abdominal  wall,  or  to  the  omentum, 
or  to  some  viscus,  such  as  the  uterus.  Such  a  band  is  commonly  an 
elongated  adhesion,  which  is  a  relic  of  a  previous  peritonitis.  Some- 
times, especially  in  the  young,  it  consists  of  Meckel's  diverticulum,  the 
tip  of  which  has  become  adherent  to  some  part  of  the  peritoneal 
surface.  Less  commonly  the  vermiform  appendix  or  the  Fallopian  tube 
may  be  the  cause.  An  omentum  which  has  become  adherent  at  some 
point  of  its  free  edge  may  become  in  whole  or  in  part  rolled  up  and 
sufficiently  cord-like  to  produce  obstruction.  Such  a  condition  of  the 
omentum  may  be  met  with  in  association  with  long-standing  femoral 
or  inguinal  hernia.  The  pedicle  of  an  ovarian  or  uterine  tumour  may 
act  in  the  same  way.  Besides  such  a  passage  of  the  bowel  under  a 
band,  it  may  become  strangulated  by  passing  through  a  slit,  sometimes 
present  in  omentum  or  mesentery  as  a  congenital  defect,  or  perhaps  as  a 
result  of  injury.  Diaphragmatic  and  obturator  hernia  must  be  borne  in 
mind,  as  well  as  the  rare  occurrence  of  hernia  into  various  pouches  of  the 
peritoneum.  The  forms  of  obstruction  included  in  this  class  occur  more 
commonly  in  males  than  females,  the  proportion  being  as  three  to  two.  It 
is  most  common  between  the  ages  of  20  and  40.  Cases  may  occur  at  any 
time  of  life,  and  strangulation  bv  Meckel's  diverticulum  is  not  uncommon 
in  childhood. 

Stricture. — Under  this  head  are  included  all  cases  of  narrowing  of 
the  bowel,  due  to  changes  in  its  walls.  These  changes  are  either  of  the 
nature  of  cicatricial  contraction  or  of  new  growth. 

The  cicatricial  form  is  by  no  means  common.  It  may  possibly  arise 
from  a  tuberculous  ulcer,  but  the  healing  of  such  an  ulcer  is  exceedingly 
rare.  It  is  improbable  that  narrowing  of  the  bowel  ever  arises  from  a 
typhoid  ulcer.  It  occurs  in  the  rectum  from  the  cicatrisation  of  syphilitic 
ulceration,  and  in  the  large  bowel  as  a  result  of  dysentery.  In  the  small 
bowel  the  most  common  form  of  stricture  is  that  produced  by  the  healing 
of  an  ulcer  which  is  of  unknown  origin.  Many  instances  have  been 
recorded  of  this  solitary  ulcer,  and  in  not  a  few  the  first  symptoms  have 
been  produced  by  the  narrowing  consequent  upon  its  healing.  It  is  most 
common  low  down  in  the  ileum,  and  is  possibly  of  syphilitic  origin.  Bare 
cases  have  been  recorded  where  the  incarceration  of  a  loop  of  small  bowel 
in  a  hernia  has  set  up  cicatricial  changes  in  its  wall,  which    have   led 


DISEASES  OF  THE  INTESTINES.  719 

to  obstruction  at  a  later  period.  Still  more  rarely  the  same  result  has 
followed  an  injury.  The  stricture  of  the  duodenum,  which  may  result 
from  a  solitary  ulcer,  is  better  considered  in  relation  to  diseases  of  the 
pylorus.  Congenital  narrowing  or  occlusion  of  the  bowel  belongs  to  the 
department  of  the  surgeon. 

The  malignant  stricture,  on  the  other  hand,  is  exceedingly  common. 
The  new  growth  which  produces  it  is  nearly  always  a  primary  one,  the 
almost  universal  form  of  the  growth  is  a  columnar-celled  epithelioma,  and 
its  seat  is  nearly  always  in  the  large  bowel,  most  commonly  in  the  rectum, 
or  sigmoid  flexure,  or  lower  part  of  descending  colon ;  less  commonly  at 
the  ileo-ceecal  valve,  or  at  the  hepatic  or  splenic  flexures.  The  growth  has 
a  tendency  to  surround  the  bowel  in  annular  fashion,  so  that  it  may 
produce  a  high  degree  of  obstruction  even  in  an  early  stage,  and  there  is 
often  a  considerable  development  of  fibrous  tissue  in  it,  which  tends  by  its 
contractile  tendency  to  increase  the  narrowing  of  the  bowel.  This  form 
of  growth  is  usually  met  with  after  middle  life,  but  it  has  been  known  to 
occur  at  the  age  of  20.  Simple  tumours,  such  as  adenomata,  fibromata, 
and  papillomata  are  also  occasionally  met  with  in  both  large  and  small 
intestine  as  the  cause  of  obstruction,  but  their  occurrence  is  not  of 
sufficient  frequency  to  require  their  consideration  at  the  bedside. 

Volvulus. — A  twisting  of  the  bowel  upon  itself,  so  as  to  lead  to 
strangulation,  is  far  more  common  in  the  sigmoid  flexure  than  elsewhere, 
owing  to  its  long  mesocolon  and  comparative  freedom  of  movement.  It 
leads  to  enormous  dilatation  of  the  bowel,  the  affected  part  possibly  filling 
two-thirds  of  the  abdomen.  There  is  great  congestion.  It  becomes  purple 
or  black  and  gangrenous.  Blood  is  commonly  extravasated  into  the 
interior,  and  some  degree  of  peritonitis  is  quickly  developed.  The  same 
accident  may  happen  to  the  caecum,  especially  when  an  unusual  amount  of 
it  has  no  mesenteric  attachment.  It  is  simply  twisted  upon  itself  to  the 
left,  and  a  turn  through  a  right  angle  may  be  sufficient  to  cause  strangu- 
lation. It  has  been  found  also  to  be  bent  upwards  upon  itself,  the  caput 
cseci  lying  on  the  ascending  colon.  More  rarely  the  volvulus  affects  the 
small  bowel,  and  occasionally  two  loops  of  small  bowel  have  become 
twisted  round  each  other.  It  is  more  common  in  males  than  females,  and 
it  seldom  occurs  before  middle  life.  As  regards  the  sigmoid  flexure,  it  is 
closely  connected  with  habitual  constipation. 

Compression  or  traction  by  adhesions  or  tumours. — This  large  group 
of  conditions  is  a  fertile  source  of  intestinal  obstruction.  As  a  result  of 
peritonitis,  the  small  bowel  may  become  matted  and  adherent,  coil  to  coil, 
to  a  variable  extent.  An  extreme  degree  of  this  matting  is  sometimes 
met  with  in  cases  of  chronic  peritonitis,  which  are  usually  of  tuberculous 
origin.  The  whole  of  the  small  bowel  from  duodenum  to  ca?cum  may  be 
gathered  up  into  a  coherent  mass,  which  defies  dissection  in  the  post- 
mortem room.  A  minor,  though  equally  fatal,  degree  of  the  same  condition 
is  found  after  repeated  attacks  of  appendicular  peritonitis,  and  such  coils 
as  lie  in  the  right  iliac  fossa  become  inextricably  welded  together.  The 
same  result  may  follow  pelvic  peritonitis  in  women.  It  may  also  follow 
the  slight  damage  to  the  peritoneum,  which  is  necessarily  inflicted  during 
abdominal  operations,  such  as  the  removal  of  the  uterine  appendages  or 
an  ovarian  tumour  ;  and  the  symptoms  of  obstruction  have  been  known  to 
supervene  some  months  or  even  years  after  such  an  operation.  All 
degrees  of  this  condition  are  met  with,  from  a  matting  of  the  whole  length 
of  the  small  bowel  to  an  adhesion  of  the  opposed  surfaces  of  a  single  loop, 


72o  ALIMENTARY  SYSTEM. 

such  as  is  sometimes  found  after  the  release  of  a  strangulated  hernia.  In 
all  these  examples  the  lumen  of  the  affected  bowel  may  remain  of  con- 
siderable size,  but  the  obstruction  arises  partly  from  the  interference  with 
or  complete  prevention  of  peristalsis,  partly  from  the  fixation  of  the  bowel 
in  a  bent  position,  and  sometimes  from  a  definite  compression  to  which  the 
bowel  is  subjected  by  cicatricial  tissue  developed  in  and  around  its 
peritoneal  coat. 

Obstruction  may  equally  result  when  a  portion  of  the  bowel  is  fixed 
by  adhesion  to  some  part  of  the  abdominal  wall,  especially  the  pelvic 
wall,  or  to  some  viscus,  such  as  uterus  or  bladder,  or  to  a  new  growth, 
such  as  an  ovarian  or  uterine  tumour.  The  length  of  bowel  so  fixed 
may  be  extremely  smalL  Such  cases  may  arise  after  the  release  of  a 
strangulated  and  inflamed  hernia.  An  adhesion  of  one  inch  of  the  small 
bowel  to  the  fundus  of  the  uterus  has  proved  fatal  five  years  after  a 
successful  operation  for  the  release  of  a  strangulated  inguinal  hernia.  The 
small  bowel  may  also  acquire  a  local  adhesion  to  a  tuberculous  mesenteric 
gland.  The  same  result  may  follow  from  any  form  of  peritonitis,  and  it  is 
not  uncommon  around  the  appendix  and  Fallopian  tube. 

An  adhesion  sufficient  to  produce  fatal  obstruction  is  not  necessarily  of 
long  standing.  Delicate  organising  adhesions  may  set  up  the  symptoms  of 
obstruction  within  ten  days  or  even  less  after  an  abdominal  operation.  They 
are  more  particularly  formed  around  a  raw  surface,  such  as  a  stump  of 
omentum  or  the  pedicle  of  an  ovarian  tumour,  and  they  may  necessitate  a 
reopening  of  the  abdominal  cavity.  There  is  in  such  cases  a  hindrance  to  peri- 
stalsis and  perhaps  some  narrowing  of  the  bowel,  but  the  obstruction  is  in 
great  measure  due  to  some  degree  of  kinking  of  the  bowel  at  the  point 
of  fixation.  An  acute  and  impermeable  kink  may  be  caused  also  by  the 
traction  of  a  band,  or  of  an  adherent  Meckel's  diverticulum  upon  any 
portion  of  the  bowel.  The  bowel,  small  or  large,  may  also  be  compressed 
by  an  abdominal  tumour.  More  especially  does  this  occur  in  the  pelvis, 
owing  to  the  comparatively  narrow  space  with  bony  walls,  and  the 
frequency  of  large  firm  tumours  in  this  situation. 

Intussusception. — If  from  any  cause  one  portion  of  the  bowel  slips 
into  the  part  immediately  below  it,  an  intussusception  is  said  to  result.  It 
can  be  readily  understood  that  on  making  a  section  across  the  bowel  at  the 
affected  spot  three  layers  will  be  met  with,  namely,  externally  a  receiv- 
ing layer,  internally  an  entering  layer,  and  between  these  two  a  middle  or 
returning  layer,  of  which  the  peritoneal  surface  is  apposed  to  the  peri- 
toneal surface  of  the  entering  layer.  The  direction  of  the  intussusception 
is  always  downwards ;  that  is,  it  follows  the  course  of  the  intestinal 
contents.  It  tends  to  increase  steadily,  the  increase  being  at  the  expense 
of  the  outer  layer,  so  that  the  head  of  the  advancing  intussusceptum 
remains  unaltered.  When  only  an  inch  or  two  of  the  bowel  is  thus 
engaged,  the  obstruction  may  be  very  slight,  and  the  symptoms  may  be 
obscure.  But  as  the  intussusception  increases  in  extent,  the  mesentery 
which  enters  with  the  bowel  into  the  receiving  layer  tends,  from  its  mode 
of  attachment,  to  pull  upon  the  intussusceptum,  so  that  its  orifice  no 
longer  faces  downwards  in  the  axis  of  the  receiving  bowel,  but  is  apposed 
to  its  side.  And  the  .obstruction  is  further  increased  by  the  extreme  con- 
gestion and  swelling  of  the  intussusceptum,  which  results  from  interfer- 
ence with  its  venous  circulation. 

An  intussusception  may  occur  anywhere  in  small  or  large  bowel,  but 
for   practical  clinical  purposes   the   condition   may  be ,  considered  to  be 


DISEASES  OF  THE  INTESTINES.  721 

confined  to  the  neighbourhood  of  the  ileo-caecal  valve.  In  most  cases 
(the  ileo-caecal  variety)  the  valve  passes  into  the  caecum  and  colon,  and 
remains  the  head  of  the  advancing  intussusceptum.  In  rare  cases  (the 
ileo-colic  variety)  the  ileum  is  protruded  through  the  valve.  The  portion 
of  bowel  affected  forms  a  thick  sausage-like  tumour,  which  may  be 
from  2  to  6  in.  in  length,  situated  at  first  in  the  right  half  of  the 
abdomen.  The  tumour,  if  sufficiently  elongated,  usually  shows  a  curved 
shape,  with  the  concavity  downwards  and  to  the  left,  this  shape  being 
impressed  upon  it  by  the  course  of  the  colon  and  by  the  attachments  of 
the  mesentery.  The  intussusceptum  may  travel  so  far  along  the  large 
intestine  that  the  valve  may  be  felt  in  the  rectum,  or  may  even  protrude 
at  the  anus. 

The  return  of  the  entering  part  of  the  bowel  is  hindered  at  first  by 
the  oedematous  swelling  which  results  from  the  pressure  on  its  veins, 
and  at  a  later  stage  by  inflammation  of  the  apposed  peritoneal  surfaces 
of  the  entering  and  middle  layers.  The  congestion  of  the  intussuscep- 
tum is  often  extreme.  It  becomes  livid  or  black,  and  there  is  commonly 
some  haemorrhage,  both  into  the  lumen  of  the  bowel  and  into  the  space 
between  the  middle  and  receiving  layers.  The  interference  with  the  blood 
supply  is  occasionally  so  extreme  that  sloughing  of  the  intussusceptum 
may  result,  and  cases  have  been  recorded  where  such  sloughing  en  masse 
of  the  intussusceptum  has  occurred,  and,  union  having  been  previously 
effected  between  the  entering  layer  and  the  point  of  junction  of  middle 
and  outer  layers,  the  lumen  has  been  thereby  restored,  and  a  natural  cure 
has  followed.  No  such  fortunate  result,  however,  can  be  anticipated  in 
actual  practice. 

Statistics  show  that  intussusception  forms  about  one-third  of  all  forms 
of  obstruction.  It  is  more  common  in  males  than  females.  It  occurs 
especially  in  children.  It  may  be  met  with  in  infants.  A  large  proportion 
of  cases  occur  during  the  first  year,  and  more  than  half  in  the  first  decade 
of  life.  The  children  are  usually  strong  and  healthy,  and  often  no  cause 
for  intussusception  can  be  found.  In  many  cases  it  seems  to  follow 
diarrhoea;  in  other  cases  a  history  of  constipation  is  obtained.  It  is 
probable  that  the  actual  starting-point  is  an  irregular  peristalsis,  which 
results  in  the  sudden  drawing  up  by  the  longitudinal  muscle  of  one  section 
of  the  bowel  over  another.  And  its  production  is  aided  by  unusual 
mobility  and  size  of  the  colon.  When  an  intussusception  is  once  formed, 
its  steady  increase  and  downward  passage  is  readily  understood,  if  it  is 
looked  upon  as  a  foreign  body,  which  is  grasped  and  passed  onwards  by 
the  receiving  bowel.  In  some  few  cases  a  polypus  or  carcinomatous 
tumour,  especially  an  epithelioma  of  the  caecum,  has  been  found  to  be  the 
head  of  the  intussusceptum,  and  to  have  led  to  its  formation. 

Foreign  bodies. — A  foreign  body  taken  in  by  the  mouth  is  rarely 
found  to  be  the  cause  of  obstruction,  since  the  bodies  that  can  pass  down 
the  oesophagus  can  usually  also  pass  through  the  bowel,  and  large  bodies, 
such  as  marbles,  coins,  and  buttons,  are  commonly  swallowed  by  children 
without  any  ill  effect.  In  rare  cases,  so  rare  as  hardly  to  enter  into  clinical 
consideration,  foreign  bodies,  such  as  coins  and  false  teeth,  have  become 
impacted  in  the  bowel.  Eather  more  commonly,  fruit  stones,  which  have 
been  swallowed  in  numbers,  have  set  up  obstruction.  They  may  accumu- 
late in  the  sigmoid  flexure,  and  may  form,  with  inspissated  faecal  matter, 
a  hard  obstructive  mass.  It  has  happened  that  the  reckless  use  of  large 
quantities  of  insoluble  salts,  such  as  those  of  magnesium  and  bismuth, 

VOL.  I. — 46 


722  ALIMENTARY  SYSTEM. 

has  resulted  in  the  formation  of  concretions.  A  much  more  common 
foreign  body  is  a  large  gallstone.  This  source  of  obstruction  is  of  sufficient 
frequency  to  demand  consideration  at  the  bedside.  It  usually  occurs  late 
in  life,  and  is  rare  before  the  age  of  50.  The  stone  commonly  enters  the 
small  intestine,  not  by  the  common  bile  duct,  but  by  ulceration  through 
the  wall  of  an  adherent  gall  bladder,  and  it  is  apt  to  be  arrested  at  the 
ileo-csecal  valve.  Fsecal  impaction  will  be  considered  in  relation  with 
chronic  constipation. 

General  effects  upon  the  bowel. — In  general,  the  bowel  below  the 
seat  of  obstruction  is  pale,  collapsed,  and  empty.  The  bowel  above  is 
distended,  injected,  and  full  of  fluid  contents.  If  the  obstruction  has  been 
of  long  standing,  as  in  carcinoma  of  the  colon,  the  portion  above,  for  6  in. 
or  more,  shows  some  thickening,  due  to  hypertrophy  of  the  muscular 
coats.  In  the  case  of  a  volvulus  of  the  sigmoid  flexure,  the  loop  of  bowel 
becomes  enormously  distended,  and  may  come  to  fill  a  large  part  of  the 
abdomen.  In  all  cases  where  some  degree  of  obstruction  has  been  present 
for  periods  of  more  than  two  weeks,  there  is  a  tendency  to  ulceration  of 
the  bowel  above  the  site  of  obstruction.  "When  the  obstruction  is  in  the 
large  bowel,  even  in  the  sigmoid  flexure  or  rectum,  it  is  noteworthy  that 
the  ulceration  is  usually  limited  to  the  caecum,  and  here  there  may  be 
found  one  or  more  deep  punched-out  ulcers.  When  the  obstruction  is  in 
the  small  bowel,  and  especially  when  it  is  due  to  stricture  about  the  ileo- 
csecal  valve,  or  to  adhesions  around  the  lower  part  of  the  ileum,  the  dis- 
tended part  of  the  ileum  may  show  numbers  of  ulcers  distributed,  perhaps, 
over  several  feet  of  the  bowel.  These  ulcers  may  be  seen  to  arise  usually 
in  the  solitary  follicles.  One  or  more  of  these  ulcers,  whether  in  the  large 
or  small  bowel,  may  give  way  during  life,  and  set  up  a  fatal  peritonitis. 
Further,  there  is  a  tendency  in  a  later  stage,  especially  in  obstruction  by 
strangulation,  or  by  volvulus,  for  the  development  of  some  degree  of  peri- 
tonitis at  the  seat  of  the  disease,  owing  to  the  damage  inflicted  upon  the 
bowel. 

Finally,  it  must  be  remembered  that  the  symptoms  of  actual  obstruc- 
tion are  often  of  sudden  occurrence,  though  the  cause  of  the  obstruction, 
such  as  a  carcinoma  of  the  sigmoid  flexure,  has  been  in  existence  for  many 
months.  This  must  usually  be  attributed  to  the  impaction  of  faeces  in  the 
narrowed  bowel. 

Symptoms. — There  are  certain  cardinal  symptoms  by  which  the 
occurrence  of  intestinal  obstruction  is  to  be  recognised.  They  are 
common  to  all  forms.  (1)  Pain  is  nearly  always  a  marked  feature. 
It  may  be  very  severe  and  sudden  in  its  onset  in  cases  of  such  violent 
nature  as  strangulation,  volvulus,  and  intussusception  It  is  less  severe 
in  cases  of  more  gradual  onset,  such  as  are  due  to  adhesions  and  stricture ; 
and  in  some  cases  it  may  scarcely  be  complained  of,  though  it  is  never 
absent.  The  nature  of  the  pain  is  important.  It  differs  from  that  of 
peritonitis  in  being  paroxysmal.  The  intervals  between  the  paroxysms 
may  be  entirely  free  from  pain,  or  may  be  accompanied  by  pain  of  a  com- 
paratively dull,  aching  character.  The  paroxysms  are  probably  due  to  the 
intermittent  violent  peristalsis  of  the  uninjured  portion  of  bowel  above 
the  seat  of  obstruction.  During  the  progress  of  the  case,  the  pain  may 
lose  this  important  paroxysmal  character,  and  become  more  continuous, 
owing  to  the  supervention  of  some  degree  of  peritonitis.  On  the  other 
hand,  it  will  often  be  noticed  that  the  pain  diminishes  in  intensity  or 
entirely   ceases   as   the   fatal   event  is   approached  and    the    sensibility 


DISEASES  OF  THE  INTESTIIVZS.  723 

becomes  progressively  duller.  In  cases  of  somewhat  gradual  onset,  the 
position  to  which  the  pain  is  referred  by  the  patient  may  give  a  clue  to 
the  site  of  the  lesion ;  but  in  many  cases,  especially  of  acute  and  violent 
onset,  it  is  felt  at  the  umbilicus,  or  all  across  the  abdomen  at  this  level, 
without  regard  to  the  position  of  the  obstruction.  (2)  Tenderness  of  the 
abdomen,  though  nearly  always  present  to  some  extent,  is  not  a  very 
marked  feature  unless  some  peritonitis  coexists.  In  an  early  stage,  at 
any  rate,  where  there  is  most  need  for  an  accurate  diagnosis,  it  never 
approaches  to  the  tenderness  which  is  met  with  in  peritonitis.  (3)  Vomit- 
ing is  practically  always  present.  It  is  more  frequent  and  severe  in 
cases  of  acute  and  violent  nature  than  in  those  with  a  more  gradual  onset. 
At  first  the  vomit  consists  only  of  the  contents  of  the  stomach  and  then 
of  bile-stained  gastric  secretion,  but  sooner  or  later  it  becomes  stercor- 
aceous,  and  consists  of  a  thick,  dark  fluid,  with  a  fsecal  odour,  which  is 
doubtless  derived  from  regurgitation  of  the  contents  of  the  small  bowel 
into  the  stomach.  This  regurgitation  is  probably  due  to  the  violent  down- 
ward peristalsis  occurring  in  the  small  bowel,  which  is  more  or  less  full 
of  partly  digested  food  products  and  its  own  secretions.  By  this  peri- 
stalsis, which  acts  in  a  downward  direction  upon  the  periphery  of  the 
contained  column  of  fluid,  the  central  portion  may  be  conceived  to  be 
forced  upwards  in  the  reverse  direction,  until  it  mingles  with  the  contents 
of  the  stomach.  Stercoraceous  or  fsecal  vomiting  may  occur  within  forty- 
eight  hours  of  the  onset  of  the  illness.  It  is  most  apt  to  appear  at  an 
early  time  when  the  onset  of  the  obstruction  is  acute,  and  when  the  site 
of  the  obstruction  is  high  up  in  the  small  intestine.  Once  established, 
it  continues  throughout  the  illness.  (4)  Constipation  is  in  nearly  all 
cases  absolute  from  the  very  commencement  of  the  illness.  Although 
the  bowel  is  of  course  seldom  empty  below  the  point  of  obstruction, 
yet,  as  a  general  rule,  neither  fsecal  matter  nor  flatus  are  passed  after 
the  onset  of  the  first  symptoms.  It  may  be,  however,  that  in  cases  of 
obstruction  by  carcinoma  of  the  large  bowel,  a  little  fsecal  matter  and 
gas  may  be  passed  naturally  or  removed  by  enema  from  below  the 
stricture,  but  this  only  occurs  to  a  very  small  extent.  Such  an  occur- 
rence in  any  other  form  of  obstruction  (except  intussusception,  which 
is  separately  described)  is  exceedingly  rare,  and  the  rule  of  constipation  is 
nearly  absolute.  (5)  Distension  of  the  abdomen  is  nearly  always  present 
to  some  extent.  It  is  most  marked  in  obstruction  of  the  large  bowel  and 
in  volvulus,  and  it  is  absent  only  when  the  obstruction  is  so  high  up  in  the 
small  intestine  that  the  greater  part  of  the  intestinal  tract,  small  and 
large,  is  collapsed.  (6)  Peristalsis  is  very  often  visible  through  the 
abdominal  wall  at  an  early  stage,  in  cases  of  obstruction  of  the  small 
intestine,  and  at  a  late  stage  when  the  large  intestine  is  involved.  It  is 
often  accompanied  by  gurgling  or  rumbling,  of  which  the  patient  is  aware. 
The  coils  of  small  bowel  may  often  be  plainly  seen  arranged  trans- 
versely or  somewhat  obliquely  across  the  abdomen,  showing  distinct 
peristaltic  waves  from  time  to  time,  which  often  correspond  to  the 
paroxysms  of  pain.  Or  it  may  be  that  only  slight,  gently  rounded 
eminences  may  be  seen  at  some  part  of  the  abdominal  surface,  which,  on 
careful  observation,  may  be  noticed  to  alter  in  shape,  size,  or  position,  or 
disappear  from  time  to  time.  It  is  generally  possible  to  hear  the  peri- 
staltic movements  with  the  stethoscope,  even  when  they  are  not  visible. 
The  observation  of  peristalsis,  either  by  eye  or  ear,  is  an  important  point, 
as  serving  to  distinguish  obstruction  from  peritonitis.     (7)  The  urine  is 


724  ALIMENTARY  SYSTEM. 

generally  diminished  in  amount,  and  may,  especially  in  acute  cases,  con- 
tain a  trace  of  albumin.  The  diminution  is  more  marked  in  acute  cases 
where  the  small  intestine  is  affected,  than  in  the  more  chronic  forms  of 
obstruction  of  the  large  intestine. 

In  order  to  obtain  a  clear  picture  of  the  symptoms  of  obstruction, 
as  produced  by  the  multifarious  causes  already  detailed,  a  distinction 
must  be  made  between  acute  cases,  where  the  onset  is  sudden  and 
a  grave  condition  is  rapidly  developed,  and  chronic  cases,  where  the 
onset  is  more  gradual  and  there  is  more  delay  before  a  very  grave 
condition  is  reached.  In  both  these  classes  there  is  the  same  train  of 
symptoms  arising  from  the  interference  with  the  action  of  the  bowels: 
but  in  the  acute  class  there  are  superadded  more  severe  consti- 
tutional symptoms,  which  are  due  to  the  damage  inflicted  upon  the 
bowel  at  the  point  of  obstruction.  A  distinction  between  the  acute  and 
the  chronic  class  is  a  clinical  one,  and  it  does  not  correspond  precisely  to 
any  pathological  classification  of  the  causes  of  obstruction.  But  it  may 
be  said  that  to  the  class  of  acute  cases  belong  instances  of  strangulation, 
of  volvulus,  of  obstruction  by  a  gallstone,  some  examples  of  intussuscep- 
tion, and  some  examples  of  obstruction  by  adhesion  or  compression ;  while 
the  type  of  the  chronic  form  is  presented  by  the  obstruction  produced 
by  a  new  growth  of  the  large  bowel,  and  sometimes  by  cases  due  to 
adhesions  or  compression.  The  symptoms  of  intussusception  differ  in 
some  respects  from  those  of  the  other  forms,  so  that  they  are  best  con- 
sidered apart. 

An  acute  case. — The  patient  is  suddenly  seized  with  severe  pain  in 
the  abdomen,  commonly  referred  by  him  to  the  umbilicus,  or  roughly, 
across  the  belly.  He  vomits  within  a  very  short  time,  often  within  a 
minute  or  two,  though  sometimes  there  is  an  interval  of  a  few  hours, 
during  which  the  pain  may  increase  in  severity.  As  a  rule,  the  vomiting 
continues  through  the  whole  course  of  the  illness,  the  vomited  matter 
becoming  stercoraceous  within  a  variable  period,  sometimes  within  forty- 
eight  hours  of  the  onset,  or  even  less.  Occasionally,  towards  the  end,  the 
vomit  may  contain  a  little  altered  blood.  The  pain  is  always  to  some 
extent  paroxysmal.  The  intervals  between  the  paroxysms  are  not,  as  a 
rule,  free  from  pain,  but  there  is  not  the  continuous  unchanging  character 
of  the  pain  of  peritonitis.  The  vomiting,  too,  is  accompanied  by  retching, 
which  may  be  extremely  distressing,  and  it  differs  in  this  respect  from  the 
vomiting  associated  with  peritonitis.  Constipation  is  usually  complete 
from  first  to  last.  Neither  fgecal  matter  nor  flatus  is  passed,  although 
the  patient  may  feel  a  call  to  stool  from  time  to  time. 

The  abdomen  rapidly  becomes  distended,  the  more  so  the  lower  in  the 
bowel  is  the  obstruction.  It  may  be,  on  the  other  hand,  that  when  the 
obstruction  is  high  up  in  the  ileum,  or  in  the  jejunum,  that  the  abdomen, 
although  rigid,  is  yet  flat.  There  is  seldom  any  great  degree  of  tenderness 
at  first,  unless  some  peritonitis  coexists,  but  there  is  a  considerable  feeling  of 
soreness.  A  very  important  indication  is  the  detection  of  distended  coils  of 
intestines  and  of  visible  peristalsis.  In  the  absence  of  these  signs,  gurgling 
will  usually  be  heard  with  the  stethoscope,  which  is  rarely  if  ever  the  case 
in  a  general  peritonitis.  There  is  sometimes  hiccough,  the  tongue  rapidly 
becomes  dry  and  furred,  the  mouth  is  dry,  and  thirst  is  distressing.  The 
urine  is  always  scanty,  sometimes  almost  entirely  suppressed,  and  it  may 
become  albuminous.  The  temperature  is  usually  subnormal  towards  the 
end ;  it  may  be  normal  or  slightly  raised  in  the  earlier  part  of  the  illness, 


DISEASES  OF  THE  INTESTINES.  725 

"but  it  seldom  reaches  101°.  The  general  condition  is  alarming  from  the 
very  first.  The  pulse  is  much  quickened,  and  becomes  progressively 
feebler  through  the  illness.  The  face  becomes  pinched  and  the  eyes 
sunken.  The  patient  becomes  apathetic,  his  voice  is  feeble,  his  hands  are 
cold  and  damp,  and  inclined  to  be  blue.  Profuse  sweats  break  out  on  the 
forehead,  and  when  this  point  is  reached  death  is  at  hand.  The  duration 
of  this  class  of  illness,  if  unrelieved  by  surgery,  is  seldom  prolonged 
beyond  one  week,  and  in  some  cases  death  may  occur  as  early  as  the  third 
day.  Such  is  an  outline  of  a  case  of  strangulation  of  the  bowel.  It 
remains  to  add,  that  in  volvulus  of  the  sigmoid  flexure  there  is  commonly 
an  enormous  distension  of  the  abdomen,  which  may  be  in  great  part  filled 
by  the  inflated  and  twisted  portion  of  the  bowel.  This  form  of  obstruc- 
tion, moreover,  is  often  deceptive,  especially  when  the  caecum  is  affected. 
On  the  one  hand,  vomiting  and  pain  are  often  inconspicuous  features,  so 
that  the  onset  may  be  less  alarming  than  in  other  forms.  On  the  other 
hand,  collapse  may  be  more  severe,  and  may  set  in  with  surprising  sudden- 
ness at  an  early  period,  and  in  these  cases  a  large  portion  of  the  bowel  is 
often  found  to  he  completely  strangulated  and  gangrenous,  and  death 
may  occur  within  the  first  forty-eight  hours. 

A  chronic  case. — Obstruction  by  a  growth  of  the  sigmoid  flexure 
may  be  taken  as  the  type  of  a  chronic  case.  It  is  common  but  by  no 
means  constant  to  elicit  a  history  of  increasing  constipation,  or  constipa- 
tion alternating  with  diarrhoea,  extending  back  over  some  weeks  or  months. 
Sometimes  there  is  a  distinct  history  of  diarrhoea,  and  a  misconception  on 
this  point  must  be  guarded  against  by  personal  and  constant  observation 
of  the  stools.  It  will  be  found  that  the  alleged  diarrhoea  consists  merely 
of  the  frequent  passage  of  small  quantities  of  thin  faecal  fluid,  which  has 
strained  through  the  stricture  without  giving  any  real  relief  to  the  con- 
stipation. And  sometimes  with  this  there  may  be  a  passage  of  small 
quantities  of  blood.  It  is  sometimes  noticed  that  the  motions  have  been 
narrowed,  but  the  absence  of  this  appearance  is  of  no  diagnostic  importance. 
Sooner  or  later  the  constipation  becomes  absolute,  the  abdomen  becomes  dis- 
tended, and  purgatives  produce  no  effect  beyond  pain  or  discomfort.  Often 
this  point  is  reached  suddenly,  the  actual  cause  of  obstruction  being  probably 
the  impaction  of  a  hard  faecal  mass  in  the  narrowed  bowel,  for  it  may  be 
found  post-mortem  that  a  malignant  stricture  which  has  proved  fatal  will 
still  admit  the  little  finger.  Even  after  the  actual  obstruction  has  begun 
there  may  be  a  passage  of  faecal  matter  or  of  flatus,  either  naturally  or  in 
response  to  an  enema,  but  this  comes  only  from  the  bowel  below  the 
obstruction,  and  must  de  discounted.  It  is  more  likely  to  occur,  the  higher 
in  the  large  bowel  is  the  seat  of  obstruction. 

There  may  be  impaired  resonance  in  one  or  both  flanks,  and,  as  a  rule, 
the  distension  of  the  abdomen  is  more  general  than  in  strangulation  of 
the  small  bowel,  in  which  case  the  prominence  occurs  mainly  in  front  and 
less  at  the  sides.  A  tumour  may  be  within  reach  of  the  finger  by  the 
rectum,  but  it  is  seldom  to  be  felt  in  the  abdomen,  owing  to  the  distension. 
The  symptoms  that  have  been  already  detailed  as  following  obstruction  of 
the  small  bowel,  now  develop,  but  with  less  rapidity.  The  abdomen  becomes 
more  and  more  distended  day  by  day,  vomiting  sets  in  and  becomes  sooner 
or  later  stercoraceous,  but  pain  is  seldom  severe,  and  may  be  entirely 
absent.  The  appetite  is  lost,  the  tongue  becomes  thickly  furred,  and  then 
dry.  Peristaltic  movements  of  the  small  intestine  may  become  visible. 
The  symptoms  of  collapse  set  in,  and  death  occurs  commonly  in  the  course 


726  ALIMENTARY  SYSTEM. 

of  the  second  week,  though  it  is  sometimes  much  later.  In  some  cases 
death  may  be  hastened  by  the  onset  of  peritonitis,  due  to  the  rupture  of  a 
distension-ulcer  in  the  caecum. 

Intussusception. — The  symptoms  of  an  intussusception  are  more 
variable  than  those  of  other  forms  of  obstruction.  The  majority  of  cases 
are  of  an  acute  kind.  There  is  the  same  sudden  onset  of  pain,  which  is 
more  or  less  paroxysmal,  and  the  same  vomiting,  as  in  cases  of  strangula- 
tion of  the  bowel  already  described.  Perhaps  it  may  be  said  that  in  the 
adult  both  these  symptoms  are  rather  less  urgent  than  in  cases  of  strangu- 
lation. But  in  the  child  the  pain  is  apparently  severe.  "With  each 
paroxysm  he  cries  aloud,  writhes,  draws  up  and  extends  his  legs,  and  may 
become  pale  and  faint.  The  vomit  consists  of  the  contents  of  the  stomach 
and  later  of  bile-stained  fluid.  In  adults  and  older  children  it  may 
become  stercoraceous,  but  this  is  not  so  common  as  in  other  forms  of 
obstruction,  and  in  the  young  children  who  are  more  particularly  the 
victims  of  intussusception  it  is  decidedly  rare.  The  onset  may  be  followed 
by  an  action  of  the  bowels,  but  with  this  exception  the  constipation  is 
absolute  in  the  child.  There  is,  however,  frequent  straining,  which  is  very 
characteristic  of  this  affection,  and  from  time  to  time  mucus  and  blood 
are  usually  passed.  In  the  adult  the  constipation  may  be  as  absolute  as 
in  cases  of  strangulation,  but  in  some  instances  there  is  a  passage  of  a 
small  quantity  of  liquid  fasces  from  time  to  time,  to  which  the  misleading 
term  "diarrhoea"  is  commonly  applied  by  the  patient's  friends.  The 
difficulty  which  is  thus  introduced  into  the  diagnosis  is  usually  counter- 
balanced by  the  occurrence  of  tenesmus  and  the  passage  of  blood,  which 
symptoms  occur  in  about  50  per  cent,  of  cases,  and  are  of  great  distinctive 
importance.  The  abdomen  is  at  first  but  little  distended,  and  scarcely 
tender.  Between  the  paroxysms  of  pain  it  may  even  be  flaccid.  Its  con- 
dition will  thus  commonly  permit  the  recognition  of  the  characteristic 
sausage-shaped  tumour  which  has  been  already  described.  This  is  usually 
met  with  in  the  right  half  of  the  abdomen,  but  it  may  lie  at  any  point  of  a 
semicircular  line  drawn  from  the  right  to  the  left  iliac  fossa  round  the 
umbilicus.  It  may  be  firm  and  doughy  and  may  have  a  sharp  outline, 
but  any  great  distension  of  the  abdomen  may  render  it  indistinct.  The 
head  of  the  intussusceptum  may  in  children  often  be  felt  in  the  rectum,, 
and  it  can  be  distinguished  from  a  tumour  or  a  prolapse  by  the  fact  that 
the  finger  can  be  passed  completely  round  it  between  it  and  the  rectal 
wall.  A  tumour  can  be  felt  in  the  abdomen  in  about  50  per  cent,  of  all 
cases.  The  temperature  is  usually  normal,  though  it  may  be  raised  3a 
or  4°  at  a  late  stage.  The  course  of  the  illness,  and  the  general 
condition  of  the  patient  are  commonly  the  same  as  in  the  case  of  strangu- 
lation. Vomiting  continues,  the  tongue  becomes  dry,  the  eyes  sink  in,  the 
face  becomes  pinched,  and  collapse  sets  in  as  a  rule  about  the  third 
or  fourth  day,  though  life  may  be  prolonged  for  a  week.  The  rate  of 
mortality  varies  inversely  with  the  age  of  the  child,  and  intussusception 
is  exceedingly  fatal  during  the  first  year  of  life. 

The  illness  may,  however,  run  a  much  milder  and  more  chronic  course, 
particularly  in  adults,  and  it  may  then  present  great  difficulty  of  diagnosis. 
In  such  cases  the  intussusception  is  small,  the  lumen  remains  open,  and 
obstruction  is  incomplete.  The  onset  may  be  much  less  marked  and  less 
sudden,  so  that  careful  questioning  may  be  necessary  to  elicit  a  clear 
history  of  it.  The  salient  features  of  the  illness  are  paroxysmal  griping 
pain  in  the  abdomen,  occasional  tenesmus,  the  passage  from  time  to  time 


DISEASES  OF  THE  INTESTINES. 


727 


of  small  quantities  of  faecal  matter  and  of  blood,  with  occasional  vomiting. 
In  this  condition  the  patient  may  continue  for  several  weeks  or  even 
months,  with  progressive  emaciation  and  increasing  feebleness,  and  so  die, 
unless  relieved.  Or  it  may  be  that  after  the  lapse  of  some  weeks  or 
months  an  acute  obstruction  may  suddenly  arise.  Careful  examination 
under  an  anaesthetic  will  as  a  rule  reveal  the  characteristic  tumour  in  some 
part  of  the  region  between  the  right  iliac  fossa  and  the  umbilicus. 

Diagnosis. — In  all  cases  of  intestinal  obstruction  an  attempt  must 
be  made  to  ascertain  the  cause  and  position  of  the  disease.  Often,  however, 
this  is  impossible,  or  the  evidence  may  be  only  sufficient  to  warrant  a 
guess. 

Anatomical. — In  the  first  place  must  be  considered  the  question 
as  to  whether  the  obstruction  is  situated  in  the  small  or  the  large 
bowel.  This  point  can  generally  be  determined  by  those  differences 
in  the  character  of  the  onset  and  in  the  early  symptoms  which  are 
contained  in  the  descriptions  already  given.  It  may  be  generally  stated 
that  the  higher  up  in  the  intestinal  tract  the  lesion  is  situated,  the 
more  violent  are  the  early  symptoms,  and  the  quicker  is  the  arrival  of 
the  collapse  which  precedes  death.  An  exception,  however,  must  be 
made  of  volvulus  of  the  caecum  or  sigmoid  flexure.  The  vomiting  follows 
the  initial  pain  more  quickly,  and  it  continues  to  be  more  severe,  and 
more  quickly  becomes  stercoraceous.  At  the  same  time  the  urine  is 
more  diminished.  Additional  information  can  be  obtained  from  the  shape 
of  the  abdomen,  which  tends  to  be  more  centrally  distended  in  obstruction 
of  the  small  bowel,  and  more  uniformly  distended  both  as  to  flanks  and 
centre  when  the  colon  is  involved.  The  form  of  the  coils  of  the  small 
intestine  may  often  be  recognised  on  the  anterior  abdominal  wall,  and  the- 
pouches  of  the  large  intestine  may  also  be  distinguished  in  the  same  way. 

And,  further,  by  palpation  and  percussion,  the  emptiness  or  fulness  of 
the  ascending  and  descending  parts  of  the  colon  can  often  be  ascertained. 
The  practice  of  endeavouring  to  locate  the  position  of  the  lesion  in  the 
large  bowel  by  means  of  a  long  tube,  or  by  the  injection  of  fluid,  is 
practically  worthless.  In  cases  of  carcinoma,  situated  low  down  in  the 
large  intestine,  the  motions  may  have  been  narrowed  before  the  onset  of 
obstruction ;  but  the  absence  of  this  sign  is  of  no  diagnostic  value. 

Pathological. — If  the  evidence  points  to  the  small  bowel  as  the 
site  of  the  obstruction,  the  field  of  possible  conditions  is  very  large, 
and  accurate  knowledge  of  all  the  facts  bearing  on  their  causation 
is  necessary  for  diagnosis.  The  previous  history  of  the  patient  must 
be  examined  with  scrupulous  care,  bearing  in  mind  the  importance 
of  past  peritonitis  having  a  pelvic,  appendicular,  or  other  origin ;  of 
previous  hernia,  of  previous  abdominal  operation  or  injury,  and  of  pre- 
vious symptoms  of  any  kind  pointing  to  abdominal  disease.  A  history 
of  tuberculosis  in  the  patient  or  his  family  may  be  of  importance, 
and  previous  biliary  colic  in  an  elderly  patient  may  be  suggestive. 
A  history  of  gradually  increasing  constipation,  culminating  in  an  acute 
onset,  is  sometimes  obtained  in  cases  of  obstruction  by  adhesion  and  by 
compression,  and  it  may  be  elicited  only  by  leading  questions.  The 
relative  frequency  of  the  various  forms  of  obstruction  at  different  ages 
must  be  taken  into  consideration ;  the  frequency  of  intussusception  in 
children,  and  of  strangulation  by  Meckel's  diverticulum  in  children  and 
adolescents,  being  especially  borne  in  mind.  Finally,  the  exact  mode  of 
onset  may  afford  some  clue.     In  all  cases  the  hernial  apertures  within 


728  ALIMENTARY  SYSTEM. 

reach  must  be  carefully  examined,  but  it  must  be  recognised  that  an 
incomplete  hernia  may  escape  detection. 

If  the  evidence  points  to  the  large  bowel  as  the  site  of  the  obstruction, 
the  field  of  possible  causes  is  smaller.  The  great  preponderance  of  new 
growth,  and  its  frequency  in  certain  positions,  have  been  already  men- 
tioned. A  history  of  previous  constipation,  perhaps  increasing  in  severity, 
with  some  anaemia,  emaciation,  and  failure  of  general  health,  may  often  be 
obtained,  and  will  point  strongly  to  this  condition.  It  must  be  remembered 
also  that  malignant  disease  of  the  intestine  may  occur  at  a  comparatively 
early  age,  and  cases  have  been  met  with  at  the  age  of  20.  A  history 
of  syphilis  or  dysentery,  or  of  previous  abdominal  operation  or  injury,  may 
also  be  of  importance. 

Differential. — (1)  Acute  peritonitis  may  present  some  difficulty.  In 
a  general  peritonitis  there  is  a  more  continuous  pain.  The  abdomen 
is  much  more  tender,  there  is  commonly  some  rise  of  temperature,  the 
vomiting  is  attended  with  less  muscular  effort,  and  the  vomited  material 
does  not  become  stercoraceous.  Further,  there  is  no  movement  what- 
ever of  the  intestinal  coils  to  be  detected  by  the  eye  or  with  the 
stethoscope.  In  one  class  of  peritonitis,  namely,  that  localised  around 
and  originating  in  the  vermiform  appendix,  there  is  sometimes  a  close 
resemblance  to  intestinal  obstruction,  and  a  mistake  is  often  made.  The 
difficulty  arises  more  especially  when  the  peritonitis  is  limited  to  the 
right  lower  q.uadrant  of  the  abdomen,  and  in  consequence  of  the  fixation  of 
the  bowels  so  caused  there  is  a  general  intestinal  distension,  and  perhaps 
some  peristalsis  becomes  visible.  The  diagnosis  can  be  made  by  noting 
the  difference  between  the  right  iliac  region  and  the  rest  of  the  abdomen, 
as  regards  pain,  tenderness,  peristalsis,  and  percussion-note,  and  perhaps  a 
history  of  previous  inflammation  around  the  appendix  may  be  obtained. 
(2)  Enteritis  is,  as  a  rule,  associated  with  diarrhoea,  and  no  difficulty  in 
diagnosis  can  arise.  Earely,  however,  in  certain  severe  cases  already 
mentioned,  there  may  be  constipation,  vomiting,  distension  of  abdomen,  and 
paroxysmal  pain.  The  distinction,  which  in  such  cases  is  difficult,  must 
depend  on  the  difference  in  the  mode  of  onset,  on  the  fever  which  is  usually 
present,  and  on  the  facts  that  flatus  may  be  passed,  and  that  the  constipa- 
tion is  not  absolute  from  the  first,  but  is  commonly  preceded  by  some 
looseness  of  the  bowels.  (3)  In  chronic  constipation,  the  only  confusion 
can  be  with  a  new  growth  or  compression  of  the  large  bowel,  and  a  careful 
investigation  of  the  history  must  be  relied  on  for  the  distinction,  unless 
impacted  faecal  matter  can  actually  be  felt  per  rectum.  (4)  Lead  colic 
must  always  be  borne  in  mind,  and  the  gums  examined.  Though  the  pain 
and  vomiting  may  resemble  those  of  obstruction,  and  the  constipation  is 
usually  complete,  yet  the  symptoms,  as  a  whole,  are  less  alarming ;  there  is 
less  quickening  of  the  pulse,  and  less  marked  constitutional  disturbance. 
(5)  Eenal  and  biliary  colic  may  lead  to  error  on  rare  occasions.  There  is 
the  sudden  onset  of  pain,  which,  in  the  case  of  biliary  colic  at  any  rate,  can 
sometimes  not  be  accurately  localised  by  the  patient,  but  is  referred  vaguely 
to  the  umbilical  region.  There  is  severe  vomiting.  There  is  often  constipa- 
tion, and  it  is  sometimes  noticed  that  a  biliary  colic  is  accompanied  by 
some  degree  of  flatulent  distension  of  the  abdomen.  Attention  must  be 
directed  to  such  points  as  previous  colic,  localisation  of  the  most  intense 
pain  about  the  right  costal  margin  or  in  the  loins,  the  presence  of  an 
icteric  tint  of  the  conjunctivae,  the  continuous  character  of  the  pain,  and 
the  absence  of  signs  of  increased  intestinal  peristalsis.     (6)  The  rare  con- 


DISEASES  OF  THE  INTESTINES.  729 

dition  known  as  acute  hemorrhagic  pancreatitis  may  be  indistinguishable 
from  an  intestinal  obstruction.  If  the  abdomen  should  be  explored 
in  this  condition,  it  is  important  that  the  operator  should  be  familiar 
with  the  appearance  presented  by  a  fat -necrosis,  which  is  commonly 
present. 

Prognosis. — Any  form  of  intestinal  obstruction  is  a  grave  condition, 
and  in  nearly  all  cases  the  natural  tendency  is  towards  speedy  death. 
But,  owing  to  the  steady  advance  in  surgery,  the  prognosis  becomes  more 
favourable  year  by  year.  The  acute  forms  of  obstruction,  which  are 
usually  associated  with  severe  damage  to  the  bowel  wall,  prove  uniformly 
fatal  if  left  unrelieved,  and  the  recovery  of  the  patient  will  depend  mainly 
on  the  earliness  of  operation  and  the  technical  skill  of  the  operator.  Cases 
of  recovery  are  now  common.  In  the  more  chronic  forms,  especially  those 
produced  by  growth  in  the  large  bowel,  there  is  less  immediate  danger 
to  life.  But  though  relief  to  the  obstruction  is  readily  given  by  operation, 
in  some  cases  the  growth  cannot  be  removed,  and  it  must  be  left  to  run  its 
course  unchecked. 

Treatment. — The  feeding  of  a  patient  suffering  from  acute  intestinal 
obstruction  is  a  matter  of  the  first  importance.  It  is  certainly  use- 
less and  probably  harmful  to  attempt  to  give  any  nourishment  by  the 
mouth.  When  the  mouth  is  very  dry  and  there  is  great  complaint 
of  thirst,  small  quantities  of  iced  barley-water  may  be  allowed,  but 
even  this  should  be  used  as  sparingly  as  possible.  The  patient's  strength 
must  be  maintained  by  such  food  as  can  be  assimilated  from  the  rectum. 
Nutrient  enemata  (4  oz.  for  an  adult),  each  containing  milk,  strong 
beef -tea,  the  white  of  an  egg,  and  a  teaspoonful  of  liquor  pancreaticus, 
must  be  given  at  least  every  four  hours  ;  and  if  there  is  any  irritability 
of  the  rectum  or  sign  of  the  return  of  the  enema,  a  nutrient  supposi- 
tory may  be  given  alternately  with  the  enema  every  three  or  four  hours. 
The  replacement  of  one  enema  in  the  twenty-four  hours  by  half  a  pint 
or  more  of  warm  water,  containing  an  ounce  of  brandy,  is  of  use  in  re- 
lieving thirst.  In  the  next  place,  something  must  be  done  to  allay  the 
pain.  Hot  fomentations,  with  or  without  belladonna,  are  certainly  of  some 
use ;  but  in  all  cases,  except  where  operative  measures  can  be  undertaken 
at  once,  some  morphine  is  necessary.  In  quarter-grain  doses  subcutaneously 
its  effect  is  very  striking.  The  pain  is  to  a  great  extent  relieved,  the 
peristalsis  is  less  violent,  the  pulse  becomes  slower,  the  feelings  and  looks 
of  the  patient  undergo  improvement.  It  must  be  remembered,  however, 
that  this  apparent  improvement  is  fallacious  and  temporary,  and  that  it 
may  obscure  the  gravity  of  the  case.  The  use  of  morphine  may  undoubtedly 
postpone  death,  but  it  can  do  no  more.  Washing  out  of  the  stomach  is 
often  found  to  contribute  to  the  patient's  comfort,  acting,  as  it  seems  to  do, 
by  allaying  the  distressing  peristalsis.  As  regards  more  active  measures,  it 
should  be  made  a  routine  practice  to  administer  skilfully  a  large  enema. 
No  harm  can  result,  no  time  is  lost,  and  it  is  possible  that  a  mistake  in 
diagnosis  may  thereby  be  obviated.  After  a  fair  trial  there  is  no  object  in 
its  repetition. 

It  may  be  said  that  in  all  cases  of  acute  obstruction,  abdominal  explora- 
tion, as  soon  as  may  be,  affords  the  only  chance.  The  mortality,  even  with 
the  help  of  surgery,  is  still  very  large  ;  but  a  great  part  of  this  mortality  is 
due  to  delay,  for  which  an  over  free  use  of  opium  is  often  responsible.  The 
great  advance  in  abdominal  surgery  renders  it  possible  to  cope  successfully 
with  nearly  every  kind  of  intestinal  obstruction,  and  examples  of  the  cure 


73o  ALIMENTARY  SYSTEM. 

of  cases  which  have  up  to  this  time  inevitably  proved  fatal  are  now 
abundant.  Bands  may  be  found  and  divided,  even  old  and  complicated 
adhesions  have  been  separated,  a  volvulus  has  been  untwisted,  and  in- 
superable obstruction  due  to  adhesions  has  been  circumvented  by  the 
establishment  of  intestinal  anastomosis.  In  some  cases  of  old  and  compli- 
cated adhesions  and  matting  of  intestines,  such  as  is  sometimes  met  with  as 
the  result  of  peritonitis  around  the  appendix,  and  more  commonly  as  a  result 
of  tuberculous  peritonitis,  restoration  of  the  freedom  of  the  bowel  may  be 
impossible.  In  some  such  cases  there  is  a  possibility  of  making  an  anasto- 
mosis between  suitable  portions  of  the  bowels.  In  some  instances,  however, 
surgery  is  powerless.  In  such  cases  the  puncture  of  the  bowels  through 
the  abdominal  wall  with  a  fine  trocar  is  perfectly  safe,  and  may  be  fre- 
quently repeated  ;  but  such  short  lengths  of  bowel  only  can  be  emptied  of 
gas  in  this  way,  that  the  relief  is  of  short  duration,  and  often  trifling  in 
amount. 

All  that  has  been  said  as  to  the  management  of  a  case  of  acute  obstruc- 
tion holds  good  in  the  chronic  forms,  though  nutriment  may  sometimes  be 
administered  by  mouth.  There  is,  however,  more  time  allowed.  A  trial  of 
copious  enemata  preceded  by  an  injection  of  4  oz.  of  olive  oil,  administered 
by  a  long  tube,  may  be  made  and  repeated.  And  if  there  is  any  chance 
that  the  cause  of  the  obstruction  is  a  fsecal  impaction,  there  is  no  harm  in 
giving  castor-oil  by  the  mouth.  If  it  fails,  the  patient's  condition  is  in  no 
way  aggravated.  The  majority  of  cases  can  here  again  be  dealt  with  suc- 
cessfully by  surgery,  and  by  surgery  alone.  The  details  belong  to  the 
surgeon's  province,  but  colotomy  will  in  nearly  all  cases  afford  relief.  In 
many  cases  of  carcinoma  of  the  sigmoid  flexure,  which  is  by  far  the  most 
common  cause  of  this  form  of  obstruction,  the  growth  can  at  the  time,  or 
subsequently,  be  entirely  removed,  and  the  integrity  of  the  bowel  may 
be  restored.  In  the  case  of  growth  about  the  caecum  and  ascending 
colon,  the  establishment  of  anastomosis  between  the  small  bowel  and 
some  part  of  the  colon  below  the  obstruction  affords  a  reasonable  hope 
of  success. 

As  regards  the  treatment  of  intussusception,  some  special  points  are  to 
be  noted.  The  general  management  of  the  patient  as  regards  diet,  opium, 
and  local  applications  is  the  same  as  in  other  forms  of  intestinal  obstruc- 
tion ;  but  the  condition  is  one  which  will  clearly  be  aggravated  by  a  pur- 
gative or  an  enema.  In  the  case  of  an  acute  intussusception,  an  attempt 
should  always  be  made  at  reduction,  and  in  a  great  many  instances  this  can 
be  successfully  effected.  It  should  be  undertaken  by  a  surgeon  who  is 
prepared  to  operate  at  once  if  it  fails.  Air  pressure  may  be  employed  by 
means  of  simple  bellows,  or  by  means  of  Lund's  inflator ;  but  the  use  of 
fluid  is  much  safer,  more  easily  regulated,  and  more  effectual.  The  child 
should  be  placed  under  the  influence  of  chloroform,  the  buttocks  raised 
by  a  pillow,  a  tube  introduced  into  the  rectum,  packed  round  with  tow, 
and  salt-solution  at  100°  F.  may  thus  be  introduced  under  steady  control 
by  means  of  a  soft  indiarubber  tube,  and  a  funnel.  The  force  is  ob- 
tained by  raising  the  funnel,  and  a  height  of  3  ft.  above  the  anus  may 
be  safely  employed,  while  the  course  of  events  is  followed  as  far  as 
possible  by  one  hand  upon  the  tumour  in  the  abdomen,  and  the  general 
condition  of  the  child  is  carefully  watched.  In  many  cases,  reduction 
can  be  effected  in  this  way,  and  this  method  has  been  successful  even 
after  the  lapse  of  four  or  five  days.  After  reduction,  great  care  must  be 
exercised  in  the  next  few  days  to  prevent  a  return.     The  movement  of  the 


DISEASES  OF  THE  INTESTINES.  731 

intestine  must  be  kept  in  check  by  the  free  use  of  opium,  and  feeding  must 
be  by  the  rectum  only. 

In  many  cases,  however,  even  of  recent  standing,  this  method  will  be 
found  to  have  failed  to  completely  reduce  the  intussusception,  the  last 
part  of  the  intussusception  being  always  the  most  difficult  part  to  return. 
When  this  is  found  to  be  the  case,  or  when  the  intussusception  has  been 
of  some  standing  and  adhesions  have  already  formed,  immediate  surgical 
operation  affords  the  best  chance  of  relief,  and  should  in  all  cases  be  em- 
ployed without  any  delay.  Even  in  young  infants  many  successful  results 
have  been  recorded. 

CONSTIPATION 

A  natural  variation  is  met  with  in  different  individuals  as  regards 
the  action  of  the  bowels.  In  the  majority  there  is  a  call  to  stool  once  a 
day.  Some,  however,  have  an  action  of  the  bowels  only  every  other  day, 
others  habitually  twice  a  day.  In  some  individuals  symptoms  arise  if 
a  day  or  two  has  passed  without  action,  whilst  others  neither  feel  nor 
show  any  ill  effects  after  a  week's  absolute  constipation.  By  constipa- 
tion, therefore,  is  meant  a  retention  of  faeces  which  is  unnatural  in  the 
individual. 

Etiology. — The  causation  is  an  exceedingly  complex  subject,  bringing 
into  review  all  parts  of  the  body.  A  natural  healthy  action  of  the  bowels 
depends  on  a  variety  of  factors.  The  formation  of  fascal  matter  in  a  proper 
plastic  condition  for  evacuation  is  mainly  a  function  of  the  large  bowel. 
Here  water  is  taken  up  from  the  food  waste,  and  the  proper  consistence  is 
attained.  But  it  is  necessary  also  that  the  whole  process  of  digestion  in 
the  stomach  and  small  intestines  should  be  efficiently  performed,  and  that 
the  secretions  of  these  parts  and  of  the  liver  and  pancreas,  should  be 
normal  in  quantity  and  quality.  Dyspepsia  of  various  kinds  is  often 
attended  by  constipation.  Further,  it  appears  that  the  food  residue  enter- 
ing the  large  intestine  should  have  a  certain  minimal  bulk  which  allows  of 
its  passage  onwards  by  peristaltic  action.  If  it  falls  below  this  bulk,  there 
is  a  tendency  to  delay  in  its  passage  down  the  large  intestine,  to  continued 
loss  of  water,  and  consequent  hardening  of  the  fasces.  The  diet  is  therefore 
an  important  matter.  This  hardening  results  whenever  there  is  not  a  daily, 
or  at  all  events  a  regular  evacuation,  and  every  day  of  constipation  adds  to 
the  difficulty.  Thus  may  arise  habitual  constipation  in  servants,  school- 
boys, and  busy  men,  who  are  for  different  causes  pressed  for  time  in  the 
morning. 

It  is  clear  that  for  the  due  performance  of  the  function,  the  nervous 
and  muscular  mechanism  of  the  bowel  must  be  in  perfect  order.  Both 
these  are  probably  impaired  by  the  over-distension  of  the  bowel,  which 
ensues  from  constipation  of  any  origin,  and  the  evil  is  thereby  aggrav- 
ated. For  the  perfection  of  both  mechanisms  it  is  necessary  that  the  body 
as  a  whole  should  be  in  perfect  health.  Anaemia,  neurasthenia,  fever, 
and  ill-health  from  any  cause,  are  commonly  accompanied  by  constipation. 
It  is  troublesome  also  in  paraplegia  and  many  cases  of  chronic  brain 
disease.  Exercise  is  essential,  partly  by  its  general  effect  on  the  body,  partly 
perhaps  by  some  mechanical  stimulation  of  the  abdominal  muscles,  and 
perhaps  of  the  bowel.  Sedentary  habits  are  a  fertile  cause  of  persistent 
constipation,  and  thus  women  are  particularly  prone  to  be  affected. 
The  troublesome  constipation  of  diabetes  is  probably  to  be  attributed  to 


732  ALIMENTARY  SYSTEM. 

the  loss  of  water  associated  with  that  condition.  Unusual  exercise 
with  profuse  perspiration  is  often  followed  by  constipation.  A  change 
of  locality,  diet,  or  habits  will  often  induce  some  irregularity  in  a  pre- 
viously well-regulated  individual.  Finally,  a  fissure  of  the  anus  or  some 
pelvic  condition  in  women,  which  makes  defalcation  painful  or  diffi- 
cult, must  always  be  borne  in  mind.  In  many  cases  of  chronic  constipa- 
tion, it  is  extremely  probable  that  the  difficulty  is  partly  the  result  of  a 
long,  large,  and  dependent  sigmoid  flexure.  It  is  possible  that  this  is  a 
congenital  condition,  but  in  some  cases  it  is  probably  the  outcome  of 
habitual  neglect  of  the  bowels  during  early  life. 

Morbid  anatomy. — The  primary  changes  in  the  bowel  which  lead 
to  constipation  have  been  already  mentioned  in  connection  with  the 
subject  of  obstruction.  It  may  be  added  that  in  some  cases  constipation 
probably  arises  from  some  congenital  abnormality  in  the  length  and 
arrangement  of  the  sigmoid  flexure,  though  no  actual  facts  can  be  quoted. 
Important  secondary  changes  in  the  bowel  may  be  produced  by  constipation, 
but  it  must  be  remembered  that  these  are  exceedingly  rare  when  the 
great  frequency  of  constipation  is  considered.  The  sigmoid  flexure  may 
become  much  dilated,  and  may  come  to  fill  the  pelvis  and  to  exercise 
pressure  on  veins  and  nerves  on  both  sides  of  the  body.  Hypertrophy  of  the 
muscular  coat  of  the  descending  colon  may  be  met  with,  such  as  has  been 
described  in  connection  with  carcinoma  of  the  sigmoid  flexure.  Enormous 
dilatation  of  the  whole  colon  may  occur.  In  a  specimen  in  St  Thomas's 
Hospital  Museum,  taken  from  a  man,  set.  28,  who  had  suffered  from 
habitual  constipation,  the  large  intestine  measures  6  in.  in  diameter 
for  the  great  part  of  its  length,  and  the  descending  colon  is  2  in.  wider. 
More  than  fifteen  quarts  of  moderately  firm  fasces  were  removed  from 
the  large  intestine  after  death.  Ulceration  of  the  bowel  is  sometimes 
seen,  more  particularly  in  the  caecum.  The  ulcers  are  sometimes  due 
to  distension  of  the  bowel,  but  sometimes  they  are  probably  produced  by 
the  mechanical  irritation  of  hard  scybala. 

Symptoms. — The  effect  of  chronic  constipation  upon  the  patient  is 
often  surprisingly  slight.  In  many  cases  an  individual  may  with  diffi- 
culty procure  an  evacuation  by  one  means  or  another  every  three  or  four 
days,  and  yet  he  may  be  conscious  of  no  impairment  of  health.  It  is  not 
uncommon  to  see  chlorotic  girls,  who  have  had  no  action  for  a  week  or  ten 
days,  and  yet  have  no  special  symptoms.  The  chlorosis  of  young  girls  has 
indeed  been  attributed  to  constipation,  but  though  constipation  is  cer- 
tainly very  general  in  such  cases,  it  is  not  invariably  present,  and,  on  the 
other  hand,  it  may  exist  for  many  years  without  production  of  any 
anaemia. 

Some  individuals  are  subject  to  headache  when  constipated.  They  lose 
something  of  their  appetite,  and  the  tongue  becomes  furred.  They  may 
become  irritable  or  depressed,  complain  of  loss  of  energy,  and  are  dis- 
inclined to  exertion.  In  some  cases  the  mental  condition  is  more  serious, 
especially  in  neurasthenic  individuals.  They  become  seriously  depressed, 
their  thoughts  are  more  and  more  concentrated  upon  the  state  of  the 
bowels,  until  the  brooding  upon  this  subject  may  lead  them  over  the 
border  line  into  hypochondriasis. 

Sometimes  by  pressure  upon  lumbar  or  sacral  nerves,  pain  is  pro- 
duced down  the  front  or  back  of  the  thigh.  Though  this  is  more 
common  on  the  left  side,  it  may  also  occur  on  the  right.  By  pressure 
on   intrapelvic   veins,   haemorrhoids   or   varicocele   may  be  developed  or 


DISEASES  OF  THE  INTESTINES.  733 

aggravated,  and  even  oedema  of  one  or  both  feet  may  occasionally 
result.  On  examination  of  the  abdomen,  feecal  masses,  which  can  be 
indented  by  pressure,  if  the  abdominal  parietes  are  thin,  may  be  felt 
in  various  positions,  in  the  csecal  region,  under  the  liver,  or  anywhere  in 
the  course  of  the  colon.  Such  masses  in  the  csecum  must  not  be  con- 
founded with  the  inflammatory  hardening  of  perityphlitis.  They  are  most 
common  in  the  sigmoid  flexure,  where  a  large  roll  may  often  be  found.  In 
some  cases  the  rectum  is  found  to  be  completely  filled  by  hard  scybalous 
masses,  so  that  the  introduction  of  a  finger  past  the  anus  is  hardly  possible. 
This  may  even  be  the  case,  especially  in  women,  when  no  complaint  of  con- 
stipation has  been  volunteered  by  the  patient.  In  such  cases  care  must 
be  taken  not  to  be  deceived  by  a  history  of  diarrhoea.  Small  quantities  of 
fgecal  fluid  may  drain  away  at  frequent  intervals,  even  when  the  rectum 
and  sigmoid  flexure  are  almost  entirely  filled  with  impacted  scybala.  _  On 
rare  occasions  it  has  been  noticed  that  an  attack  of  constipation  in  a 
previously  healthy  individual  may  be  attended  by  a  moderate  degree 
of  fever,  the  temperature  reaching  100°  or  101°  for  a  day  or  two,  but 
such  cases  should  be  carefully  examined  for  evidence  of  disease  of  the 
appendix. 

Long-standing  constipation  may  terminate  in  a  veritable  obstruction 
by  impacted  faeces,  but  this  is  a  very  uncommon  event^  considering  the 
great  frequency  of  constipation.  It  is  more  common  in  females  than 
in  males.  The  onset  of  the  more  severe  symptoms  is  usually  gradual. 
The  constipation  becomes  less  and  less  amenable  to  treatment.  No 
doubt  a  considerable  length  of  the  colon  is  in  such  cases  distended  by 
fasces  to  such  a  degree  that  any  feeble  contractile  power  that  may  remain 
is  unable  to  dislodge  the  impacted  mass.  The  abdomen  becomes  distended, 
peristalsis  is  visible,  nausea  and  vomiting  begin,  the  vomit  acquires  a 
stercoraceous  odour,  and  the  whole  appearance  and  general  condition  are 
identical  with  those  of  a  patient  suffering  from  obstruction  due  to 
carcinoma  of  the  sigmoid  flexure.  A  differential  diagnosis  can  hardly 
be  made  save  by  means  of  the  previous  history.  In  rare  cases  the  actual 
onset  of  acute  symptoms  is  sudden.  It  is  then  due  to  the  sudden  blocking 
by  a  hard  ftecal  mass  of  an  already  partially  obstructed  bowel. 

Treatment. — In  all  cases  care  must  be  taken,  in  the  first  place,  to 
find  any  specific  cause  among  those  above  enumerated  to  which  the 
constipation  can  be  attributed,  and  to  correct  it  so  far  as  possible  by  appro- 
priate treatment.  The  patient  must  be  impressed  with  the  necessity  of 
yielding  to  any  call  of  nature  without  delay,  and  in  the  absence  of  any 
such  call  to  make  a  daily  attempt  at  a  regular  hour,  preferably  after 
breakfast.  Some  alteration  in  the  daily  habits  may  be  necessary  for  the 
deliberate  fulfilment  of  this  matutinal  function.  In  many  cases,  especially 
in  large  towns,  the  remedy  will  He  in  the  enjoinment  of  regular  exercise, 
on  horseback,  on  a  bicycle,  or  on  foot.  The  diet  must  be  rigidly  examined, 
and  though  it  may  be  apparently  healthy,  an  addition  of  further  green 
vegetables,  of  fruit  according  to  season,  of  brown  bread,  and  of  porridge, 
is  often  beneficial.  Excess  of  meat,  eggs,  and  milk  in  the  diet  must  be 
guarded  against,  and  a  tumblerful  of  water  during  dressing  before  break- 
fast should  always  be  tried. 

In  some  cases  which  are  in  an  early  stage,  nothing  further  is  necessary  ; 
or  an  aloes  pill,  cascara  sagrada,  calomel,  a  seidlitz  powder,  or  some  mineral 
water,  may  occasionally  be.  required.  But  the  constipation  has  usually 
become  a  confirmed  habit  before  the  patient  comes  under  observation, 


734  ALIMENTARY  SYSTEM. 

and  drugs  must  be  employed  with  care.  There  is  no  doubt  that  the 
majority  of  the  purgatives  which  may  legitimately  and  usefully  be 
employed  for  occasional  attacks  of  constipation  do  actual  harm  when  it 
has  become  habitual.  The  principle  of  treatment  is  to  overcome  the 
habit  patiently  and  slowly,  rather  than  to  purge.  In  the  common  type  of 
case,  aloin  is  the  safest  drug.  It  must  be  used  tentatively,  so  as  to  find 
the  exact  dose  which,  given  overnight,  produces  a  fair  action  in  the 
morning.  Commonly  a  pill  containing  2  gr.  of  aloin,  half  a  grain  of 
extract  of  belladonna,  and  a  quarter  of  a  grain  of  extract  of  nux  vomica 
will  in  an  adidt  have  this  effect.  An  addition  of  half  a  grain  of  ipecac, 
powder  is  sometimes  made  with  advantage.  It  is  wise  to  use  too  little 
aloin  rather  than  too  much.  With  the  required  pill  an  attempt  must  be 
made  to  get  a  daily  action,  by  giving  it  for  a  time  every  night.  When  a 
daily  action  has  been  thus  established,  the  use  of  the  drug  must  be 
gradually  discontinued.  At  first  the  dose  of  aloin  should  be  diminished ; 
later  the  pill  should  be  used  only  on  alternate  nights,  and  if  necessary 
an  occasional  glycerin  suppository  in  the  morning,  or  a  lozenge  contain- 
ing 5  gr.  of  precipitated  sulphur  and  1  gr.  of  acid  tartrate  of  potash 
in  the  evening  may  be  substituted.  If  the  habits  and  diet  are  at  the 
same  time  skilfully  regulated,  the  patient  may  be  often  brought  back 
to  a  healthy  condition.  Sometimes,  in  slighter  cases,  3  or  4  oz.  of 
Hunyadi  Janos,  or  Friedrichshall,  or  Eubinat  water,  with  an  equal 
amount  of  hot  water,  may  be  used  in  the  morning  before  breakfast, 
with  the  same  intention  of  intermitting  and  discontinuing  its  use  as  soon 
as  may  be.  Or  an  artificial  Carlsbad  salt  may  be  used  in  the  same  way, 
containing  30  gr.  of  sulphate  of  soda,  15  of  bicarbonate  of  soda,  and 
5  gr.  of  chloride  of  soda  in  a  tumbler  of  hot  water.  In  more  severe 
cases  it  may  be  necessary  to  give  aloin  three  times  a  day  at  first, 
always  stopping  short  of  free  purgation. 

Chronic  cases  are,  however,  often  met  with,  where  all  these  means 
fail.  The  large  bowel  has  seemingly  lost  much  of  its  muscular 
power,  and  possibly  the  sigmoid  flexure  is  large  and  dependent.  Even 
here  violent  purgatives  must  be  considered  only  as  a  last  resource.  The 
rectum  must  be  examined,  and  if  hardened  fasces  are  found  to  fill  it, 
there  is  no  other  course  to  be  pursued  than  their  mechanical  removal. 
Eecourse  must  then  be  had  to  soap-and-water  enemata,  by  the  daily  use 
of  which  and  the  occasional  use  of  castor-oil,  the  large  bowel  must  be 
kept  as  empty  as  possible,  with  the  hope  that  it  may  recover  something 
of  its  power.  At  the  same  time,  electrical  treatment  and  abdominal 
massage  may  be  employed  with  advantage.  Such  cases  may,  under  this 
treatment,  get  back  to  a  comparatively  comfortable  condition,  so  that 
with  correct  diet,  habits,  and  exercise,  and  with  an  occasional  dose  of 
castor-oil  or  aloin  pill,  a  fairly  regular  action  of  the  bowels  may  be 
obtained.  But  in  some  cases  it  must  be  realised  that  the  improvement 
is  very  slight,  and  enemata  and  aperients  of  all  kinds  may  be  required  to 
the  end  of  the  chapter.  It  has  happened  in  cases  of  complete  atony  of 
the  large  bowel,  with  impaction  of  fasces  and  definite  signs  of  obstruction, 
that  colotomy  has  been  necessary,  but  such  a  necessity  is  of  very  rare 
occurrence,  and  need  not  be  anticipated. 


DISEASES  OF  THE  INTESTINES.  735 

APPENDICITIS. 

Inflammation  of  the  vermiform  appendix  is  a  common  occurrence, 
and  it  is  important,  owing  to  the  frequency  with  which  peritonitis  is 
excited.  The  peritonitis  may  be  either  general,  or  localised  in  the 
neighbourhood  of  the  appendix.  In  the  latter  case  it  may  be  limited 
to  the  exudation  of  a  coagulable  inflammatory  material,  which  can  undergo 
absorption  and  removal  (simple  perityphlitis),  or  result  in  the  formation  of 
pus  (perityphlitic  abscess).  In  clinical  usage  the  term  appendicitis  is 
often  loosely  extended  to  denote  any  peritonitis  which  arises  around  and 
in  consequence  of  a  diseased  appendix. 

Etiology. — It  is  probable  that  appendicitis  can  only  be  recognised 
clinically  when  the  inflammation  has  involved  its  peritoneal  coat,  or  the 
peritoneum  in  its  neighbourhood ;  and  it  is  therefore  not  possible  to  dis- 
tinguish accurately  between  the  causes  which  lead  to  the  primary  disease 
of  the  appendix  and  those  which  lead  to  the  secondary  production  of  peri- 
tonitis around  it.  It  is  reasonable,  however,  to  suppose  that  the  proneness 
of  the  appendix  to  inflammatory  and  microbic  disease,  as  compared  with 
the  caecum  and  the  rest  of  the  intestinal  tract,  is  mainly  due  to  its  obsolete 
and  functionless  condition.  And  it  is  possible  that  slight  causes  of  inflam- 
mation, such  as  cold,  and  the  presence  of  indigestible  material,  which  pass 
unnoticed  in  other  parts  of  the  intestine,  may  provoke  disease  in  this 
rudimentary  organ.  There  is  evidence  also  to  suggest  that  a  severe  form 
of  appendicitis  may  be  attributed  to  a  rise  in  the  virulence  and  pathogenic 
power  of  some  of  the  micro-organisms  which  normally  inhabit  the  part, 
particularly  B.  coli  communis. 

Appendicitis,  including  under  the  term  all  the  resulting  forms  of 
peritonitis,  is  most  common  in  the  young.  More  than  50  per  cent,  of 
the  cases  occur  under  the  age  of  20,  and  only  15  per  cent,  occur  after 
the  age  of  30.  It  may,  however,  be  met  with  at  both  the  extremes  of 
life.  It  is  much  more  common  in  males  than  females,  in  the  propor- 
tion of  7  to  3.  It  occurs  in  all  occupations,  and  in  all  classes  of  society. 
The  onset  of  an  attack  may  occur  without  warning  or  apparent  cause  in 
a  healthy  individual.  In  some  cases  there  is  a  history  of  previous  con- 
stipation. Sometimes  it  is  immediately  preceded  by  an  indigestible 
meal,  or  by  an  injury  or  strain ;  but  these  factors  are  probably  of  import- 
ance only  in  setting  up  peritonitis  around  a  previously  diseased  appendix. 

Morbid  anatomy. — The  diseases  of  the  appendix  which  are  apt  to 
excite  some  degree  of  peritonitis  are — (1)  a  catarrhal  inflammation,  which 
is  more  or  less  strictly  limited  to  the  mucosa ;  (2)  an  ulceration,  which 
is  usually  due  to  the  pressure  of  a  faecal  concretion  or  a  foreign  body ; 
(3)  an  infective  inflammation,  which  involves  all  the  tissues  of  the 
appendix  wall,  and  is  always  associated  with,  and  probably  due  to,  an 
invasion  of  the  wall  by  the  bacteria  which  inhabit  the  bowel. 

A  tuberculous  ulcer  in  the  appendix  may  set  up  a  perityphlitis ;  but  it 
is  an  uncommon  cause  of  this  condition.  A  typhoid  ulcer  in  it  may  per- 
forate and  excite  a  general  peritonitis.  Actinomycosis  has  been  known  as 
the  cause  of  a  perityphlitic  abscess. 

Catarrhal  appendicitis. — This  form  is  frequent,  and  it  is  probable 
that  it  often  occurs  without  symptoms.  The  changes  are  those  of  inflam- 
mation of  mucous  membranes  elsewhere.  The  epithelium  of  the  general 
surface  and  of  the  crypts  of  Lieberkiihn  is  shed.  The  retiform  tissue 
which  forms  the  groundwork  of   the   mucosa   becomes   infiltrated  with 


736  ALIMENTARY  SYSTEM. 

leucocytes,  and  it  is  consequently  swollen.  The  lumen,  as  a  rule,  contains 
no  fpecal  matter,  but  it  may  be  occupied  by  a  mass  composed  of  leucocytes, 
granular  debris,  mucus,  and  epithelium.  The  latter,  when  derived  from 
the  crypts,  sometimes  appears  in  the  form  of  definite  casts.  In  a  later 
stage  the  basement  membrane  may  be  destroyed,  the  infiltration  becomes 
more  marked,  and  the  interior  of  the  appendix  may  come  to  be  lined,  in 
whole  or  in  part,  with  a  layer  of  raw  granulation  tissue. 

Recovery,  doubtless,  readily  occurs  in  an  early  stage  by  a  growth 
of  new  epithelium  from  the  remains  of  the  original  lining.  In  some 
cases,  however,  where  the  denudation  and  destruction  of  the  basement 
membrane  have  been  complete  over  a  large  area,  further  changes 
occur  in  one  of  two  directions.  On  the  one  hand,  the  condition  may 
become  one  of  chronic  catarrhal  appendicitis,  which  is  a  constant 
source  of  trouble.  While  the  inner  surface  continues  as  a  pus-form- 
ing granulation  tissue,  the  muscular  coats  may  be  infiltrated  with 
leucocytes  and  connective  tissue  cells,  and  there  is  great  increase  in 
their  fibrous  elements,  so  that  the  whole  wall  of  the  appendix  becomes 
thick,  rigid,  and  incollapsible.  On  the  other  hand,  union  may  occur 
between  the  apposed  granulating  surfaces,  so  that  the  lumen  of  the 
tube  may  be  in  part,  or  in  its  whole  length,  obliterated  by  the  formation 
of  fibrous  tissue.  If  obliteration  takes  place  in  the  whole  length  of  the 
tube,  the  appendix  ceases  to  be  a  source  of  disease.  It  not  uncommonly 
happens,  however,  that  obliteration  occurs  only  at  some  one  point,  and  a 
stricture  thus  results,  which  is  usually  situated  near  the  caecal  end  of  the 
organ.  The  peripheral  part  of  the  appendix  may  subsequently  become 
distended  into  a  cyst  by  its  own  secretion  of  pus,  or  muco-pus,  which 
can  find  no  outlet,  and  the  cyst  so  formed  may  be  2  in.  in  length  by  1  in. 
in  breadth.  Owing  to  the  continuance  of  inflammation  in  the  cystic 
portion,  aided  by  the  tension  of  its  wall,  rupture  or  perforation  is  not  an 
uncommon  event.  It  should  be  mentioned  that  a  similar  cyst  may  be 
developed  through  the  kinking  of  the  tube  at  its  caecal  end,  and  in  such  a 
case  the  contained  secretion  will  escape  when  the  organ  is  made  straight. 

Ulcerative  appendicitis. — Ulceration  of  the  appendix  may  occur  in 
a  late  stage  of  catarrhal  inflammation,  especially  when  a  cystic  condition 
has  been  reached.  But  the  ulceration  which  is  more  particularly  included 
under  this  head  results  from  the  pressure  of  a  fsecal  concretion  or  a  foreign 
body.  A  concretion  has  been  variously  estimated  as  being  the  cause,  in 
from  30  to  50  per  cent,  of  all  cases  of  appendicular  peritonitis.  It  is 
formed  by  the  lodgment  in  the  tube  of  a  pellet  of  fsecal  matter,  which 
becomes  moulded  by  the  peristaltic  contractions  into  an  oat-shaped  or 
oval  body,  often  resembling  a  cherry-stone.  This  loses  its  water,  and  its 
hardness  is  further  increased  by  the  deposition  of  lime  salts  upon  it.  In 
some  cases  a  foreign  body,  such  as  a  splinter  of  wood  or  a  pin,  has  been 
found  as  the  nucleus  of  a  concretion.  Two  or  more  such  concretions,  in 
various  stages  of  hardness,  may  be  found  in  the  same  appendix.  A  foreign 
body  is  much  less  common,  and  the  frequency  of  its  occurrence  has  been 
variously  estimated  as  from  4  to  12  per  cent.  All  kinds  of  small  bodies 
which  are  apt  to  be  inadvertently  swallowed  are  found,  such  as  fruit  stones, 
pips,  seeds,  pieces  of  bone,  nutshells,  shot,  nails,  pins,  bristles,  and  leaves. 
Each  such  concretion  or  foreign  body  is  apt,  by  its  pressure,  to  produce  a 
progressive  ulceration  at  the  site  of  its  impaction,  and  the  process  con- 
tinues until  the  peritoneum  becomes  involved,  or  actual  perforation  of  the 
appendix  wall  occurs. 


DISEASES  OF  THE  INTESTINES.  737 

Infective  appendicitis. — This  form  of  inflammation  is  extremely 
fatal,  and  it  is  the  cause  of  at  least  50  per  cent,  of  fatal  cases  of  general 
appendicular  peritonitis.  It  may  arise  suddenly  in  an  appendix  which  is 
cystic,  or  in  one  which  is  already  the  seat  of  ulceration,  or  in  the  case  of 
a  chronic  catarrh.  In  all  these  conditions  the  protective  epithelium  has 
been  more  or  less  destroyed.  It  may  arise  also  in  an  appendix  which 
shows  little  or  no  evidence  of  any  previous  disease.  In  all  cases  of 
infective  appendicitis  the  submucous  and  muscular  coats  are  found,  both 
during  life  and  after  death,  to  contain  numerous  bacteria,  for  the  most 
part  B.  coli  communis,  and  it  is  probable  that  the  changes  are  closely  con- 
nected with  this  invasion. 

The  changes  included  under  this  head  vary  greatly  in  severity  and 
extent.  Most  commonly  there  occurs  a  necrosis  or  sloughing  of  some 
part  of  the  wall  of  the  tube  in  its  whole  thickness.  _  Sometimes  an 
inch  or  more  of  the  appendix  may  undergo  necrosis  in  a  large  part 
of  its  circumference.  Sometimes  the  process  "occurs  in  the  whole 
circumference,  so  that  the  tip  may  die  en  masse,  or  the  organ  may 
be  more  or  less  completely  divided  into  two  parts,  and  sometimes  the 
whole  organ  may  be  detached  in  this  way  from  the  caecum.  In  other  cases 
the  necrosis  may  be  more  limited  in  degree,  and  it  may  be  indicated  upon 
the  outside  of  the  tube  only  by  a  discoloured  area,  in  which  may  be  situ- 
ated one  or  more  minute  apertures,  which  penetrate  the  peritoneal  coat, 
but  do  not  necessarily  lead  into  the  lumen.  In  rare  cases,  again,  there 
may  be  no  actual  necrosis,  but  there  may  be  observed,  microscopically,  the 
signs  of  acute  inflammation  of  the  submucous  and  muscular  coats,  includ- 
ing, perhaps,  the  formation  of  minute  abscesses  in  the  substance  of  the 

wall. 

Finally,  it  must  be  mentioned  that  the  length  and  situation  ot  the 
appendix  are  variable,  and  some  unusual  clinical  features  in  the  peritonitis, 
resulting  from  its  disease,  are  thereby  explained.  The  average  length  in 
the  male  is  3|  in. ;  in  the  female,  3  in.  The  extremes  are  about  1  m. 
and  9  in.  Mo"st  commonly  (about  44  per  cent.)  it  runs  upwards  along 
the  left  border  of  the  caecum,  or  upwards  and  inwards,  or  directly  inwards 
across  the  psoas.  It  often  (about  26  per  cent.)  lies  behind  the  caecum,  and 
its  tip  may  even  rest  on  the  right  kidney.  Often,  also  (about  17  per  cent.), 
it  hangs  down  into  the  pelvis.  In  some  cases  it  is  curled  up  on  the  tip  of 
the  caecum,  or  in  the  ileo-caecal  fossa ;  and  sometimes  it  runs  up  on  the 
outer  side  of  the  caecum.  It  has  been  found  in  the  sac  of  a  hernia.  Its 
tip  has  often  been  found  lying  to  the  left  of  the  middle  line,  and  it  may 
even  reach  the  left  psoas.  Its  variability  in  position  is  increased  also  by 
the  fact  that  the  caecum  is  sometimes  found  to  be  placed  higher  than  usual, 
and  to  have  no  relation  to  the  iliac  fossa. 

Any  one  of  the  morbid  conditions  of  the  appendix  above  described  is 
apt  to  be  attended  by  an  inflammation  of  some  part  of  the  peritoneum. 

(a)  In  the  mildest  and  commonest  form  (simple  perityphlitis),  only  that 
part  of  the  peritoneum  is  affected  which  covers  the  appendix,  the  caecum,  and 
the  coils  of  small  intestine  which  happen  to  be  situated  in  the  right  iliac  fossa. 
The  inflammatory  exudation  which  appears  on  the  peritoneal  surface,  and 
which  tends  to  accumulate  in  the  interstices  between  the  intestines,  under- 
goes coagulation,  and  the  parts  lying  in  the  right  iliac  fossa  are  thereby 
fixed,  and  form  a  firm,  coherent  mass,  which  may  usually  be  readily  felt 
with  the  hand.  Eecovery  from  such  an  attack  is  almost  invariable  ;  the 
exudation  is   mainly  absorbed,  but  is  partly  in  some  cases  replaced  by 

VOL.  I. — 47 


738  ALIMENTARY  SYSTEM. 

organised  adhesions.  A  recurrence  is  apt  to  take  place.  This  simple  peri- 
typhlitis, which  accounts  for  70  per  cent,  of  all  cases  of  peritonitis  arising 
from  disease  of  the  appendix,  is  most  commonly  associated  with  a  simple 
chronic  catarrh  of  that  organ,  but  may  arise  from  the  cystic  condition,  and 
from  the  presence  of  a  concretion  without  perforation. 

(b)  In  a  small  number  of  cases  (about  15  per  cent,  of  all  forms  of 
appendicular  peritonitis),  the  inflammation,  while  still  remaining  limited 
to  the  parts  situated  in  the  right  iliac  fossa,  assumes  a  pyogenic  char- 
acter, presumably  owing  to  the  escape  of  bacteria  from  the  diseased 
appendix.  Pus  then  accumulates  around  the  appendix  (perityphlitic 
abscess),  forming  for  itself  a  definite  cavity,  which  is  usually  Walled  in 
and  shut  off  securely  from  the  general  peritoneal  cavity  by  adherent  in- 
testines. Variations  in  the  position  of  the  abscess  will  be  mentioned  later. 
Such  a  perityphlitic  abscess  is  commonly  associated  with  an  ulcerative 
appendicitis,  due  to  a  fsecal  concretion,  or  to  a  chronic  catarrh  upon 
which  an  infective  appendicitis  has  supervened.  An  abscess  may  develop 
without  any  visible  perforation.  B.  coli  communis  is  in  nearly  all  cases 
present  in  the  pus ;  sometimes  associated  with  Streptococcus  pyogenes,  and 
perhaps  other  pyogenic  microbes. 

(c)  In  the  third  class,  about  15  per  cent,  of  all  forms  of  appendicular 
peritonitis,  the  whole  or  the  greater  part  of  the  peritoneum  is  inflamed 
(general  peritonitis).  The  inflammation  may  be  attended  with  a  coagulable 
exudation,  and  in  such  cases  recovery  is  possible ;  but,  as  a  rule,  the  whole 
peritoneal  cavity  becomes  infected  with  the  bacteria  above  mentioned,  the 
exudation  is  purulent,  the  toxic  products  of  the  bacterial  life  are  absorbed 
into  the  circulation,  and  recovery  is  a  rare  event.  A  general  peritonitis  is 
associated  with  an  infective  appendicitis,  and  with  perforation  in  the  course 
of  ulceration,  due  either  to  a  feecal  concretion  or  to  the  cystic  condition. 

Symptoms. — Simple  perityphlitis. — In  most  cases  the  onset  occurs 
suddenly,  without  any  discoverable  exciting  cause.  Sometimes,  how- 
ever, it  is  preceded  by  an  indigestible  meal,  a  strain,  or  a  direct  injury 
to  the  abdomen.  The  first  symptom  is  almost  invariably  pain  in  the 
abdomen,  which  is  slight  or  severe.  It  may  be  so  sharp  as  to  simulate  a 
renal  or  biliary  colic.  The  pain  may  be  referred  from  the  first  to  the  right 
iliac  fossa,  but  as  often  as  not  it  is  at  first  felt  all  across  the  abdomen  at 
the  umbilical  level,  and  only  shifts  to  the  region  of  the  appendix  after  the 
lapse  of  twenty-four  or  thirty-six  hours.  Occasionally,  at  a  later  stage, 
some  pain  attends  the  act  of  micturition,  owing  to  the  implication  of  some 
part  of  the  peritoneal  surface  of  the  bladder.  And  there  may  also  be  some 
pain  down  the  front  of  the  right  thigh. 

The  patient  usually  vomits  within  a  few  minutes  or  hours  after  the 
onset  of  the  pain.  The  vomiting  may  continue  at  intervals  for  a  day  or 
two,  especially  if  the  patient  is  not  under  treatment ;  but  it  is  seldom  an 
urgent  symptom.  With  the  pain  and  vomiting  are  sometimes  headache, 
a  feeling  of  chilliness,  and  general  malaise.  The  tongue  becomes  furred, 
and  the  appetite  is  lost.  The  face  may  be  flushed  or  pale,  and  expressive 
of  pain.  As  a  rule,  the  bowels  are  constipated  from  first  to  last.  Occa- 
sionally the  first  onset  of  the  pain  is  accompanied  by  one  or  two  loose 
stools,  and  in  rare  instances  the  bowels  are  loose  throughout  the  illness. 
The  urine  is  scanty  and  high-coloured,  and  often  contains  indican. 

Tenderness  in  the  right  iliac  fossa  is  constant,  and  in  an  early  stage 
it  may  be  the  only  clue  to  a  diagnosis.  It  is  often  very  acute,  and 
the  skin   is   hypereesthetic.     The   extent  of   the  tenderness  varies  with 


DISEASES  OF  THE  INTESTINES.  739 

the  amount  of  peritoneal  surface  inflamed,  but  the  greater  part  of  the 
right  half  of  the  abdomen  may  be  tender  even  in  a  case  which  is 
going  to  run  a  simple  and  favourable  course.  However  widespread,  the 
tenderness  is  always  most  marked  in  the  immediate  neighbourhood  of  the 
appendix,  and  its  maximum  point  (M'Burney's  point)  is  usually  to  be 
found  at  a  spot  one-third  of  the  way  along  a  line  drawn  from  the  right 
anterior  superior  spine  to  the  umbilicus.  This  point  is  sufficiently  constant 
to  be  of  diagnostic  use,  and  pain  or  discomfort  may  usually  be  elicited  by 
deep  pressure  at  this  spot,  even  after  the  subsidence  of  a  perityphlitis,  if 
the  appendix  remains  diseased. 

During  the  first  day  or  two  of  the  illness,  the  abdomen  is  commonly 
slightly  distended,  and  the  muscles  are  somewhat  rigid  over  its  right 
side.  As  a  rule,  the  muscular  rigidity  soon  passes  off,  and  something 
of  the  nature  of  a  tumour  can  nearly  always  be  felt  in  the  right  iliac 
fossa.  This  may  be  soft  and  ill-defined,  but  it  is  usually  fairly  hard, 
and  its  upper  and  inner  borders  are  sharp.  It  is  commonly  oval  in 
shape.  It  lies,  as  a  rule,  above  the  outer  half  of  Poupart's  ligament, 
but  occasionally  it  is  situated  nearer  to  the  middle  line  of  the  body, 
so  that  it  comes  within  reach  of  a  finger  introduced  into  the  rectum. 
It  must  be  noted,  however,  that  difficulty  in  diagnosis  may  arise  in  certain 
rare  cases,  when  the  appendix  is  situated  in  some  unusual  position.  If  it 
is  placed  partly  within  the  pelvis,  there  may  be  tenderness,  but  no  tangible 
mass  in  the  iliac  fossa.  If  it  lies  under  the  caecum,  or  upon  its  outer  side, 
tenderness  and  resistance  will  be  situated  above  the  anterior  superior 
spine,  or  even  in  the  flank.  In  all  other  respects,  such  cases  run  the 
usual  course.  The  iliac  swelling  may  be  no  larger  than  a  hen's  egg,  or  it 
may  measure  4  in.  in  transverse  and  vertical  lines.  This  inflammatory 
mass,  which  is  very  characteristic  of  perityphlitis,  is  usually  composed  of 
omentum,  a  loop  or  two  of  small  intestine,  and  the  caecum.  These  struc- 
tures are  found  to  be  congested  and  cedematous,and  the  interstices  between 
them  contain  a  variable  amount  of  coagulated  fibrinous  exudation,  which 
fixes  them  in  the  iliac  fossa  around  the  diseased  appendix.  The  size  and 
hardness  of  the  mass  are  sometimes  increased  by  fsecal  matter  which  is 
retained  in  the  affected  portion  of  the  bowel.  Eesonance  is  generally 
impaired  over  the  mass;  but  sometimes  the  note  obtained  by  gentle 
percussion  is  unaltered,  or  even  tympanitic,  if  a  coil  of  gas -containing 
bowel  happens  to  lie  on  the  surface.  Owing  to  this  fixation  of  a  portion 
of  the  small  bowel  in  the  iliac  fossa,  increased  peristalsis  occurs  occasionally 
elsewhere  in  the  abdomen.  Bumbling  and  gurgling  may  sometimes  be 
heard  and  felt,  and  peristaltic  movements  may  even  become  visible.  The 
conjunction  of  such  a  symptom  with  abdominal  pain,  vomiting,  and  con- 
stipation may  arouse  some  suspicion  of  intestinal  obstruction,  but  instances 
are  rare  where  the  diagnosis  presents  much  difficulty. 

The  temperature  rises  rapidly  at  the  onset  of  the  illness,  and  com- 
monly reaches  102°  or  104°  in  the  first  twenty-four  hours  (Fig.  91).  A 
higher  temperature  is  occasionally  met  with,  but  it  need  cause  no  anxiety. 
The  maximum  is  reached  during  the  first  three  days,  often  on  the  first 
day,  and,  as  a  rule,  there  is  a  steady  fall  from  this  point,  the  common 
duration  of  the  fever  being  from  six  to  ten  days.  Sometimes,  about  the 
beginning  of  the  second  week,  the  fever  ends  as  suddenly  as  in  pneumonia 
(Fig.  92).  Earely,  in  a  simple  perityphlitis,  without  the  formation  of 
pus,  a  secondary  rise  of  temperature  may  set  in  during  the  course  of  the 
illness  (Fig.  93).     Occasionally  the  febrile  period  is  prolonged,  and  it  may 


74° 


ALIMENTARY  SYSTEM. 


extend  over  three  or  four  weeks,  with  perhaps  a  day  or  two   of  normal 
temperature  now  and  then. 

About  the  end  of  the  first  week  the  fever  subsides,  the  tongue  becomes 
cleaner,  and  the  appetite  begins  to  return.  Perhaps  the  bowels  may  act 
naturally.  The  inflammatory  induration  in  the  groin  shows  a  progressive 
diminution  in  size,  and  it  is  less  and  less  tender.  As  a  general  rule,  all- 
acute  symptoms  are  at 
an  end  in  ten  to  fourteen 
days,  but  occasionally  a 
little  tenderness  may  per- 
sist, with  slight  fever  and 
a  furred  tongue  for  a  week 
or  two  longer.  Recovery 
from  a  simple  perityphli- 
tis, without  suppuration 
or  other  complication,  is 
almost  invariable,  though 
a  recurrence  of  the  attack 
is  exceedingly  common. 
It  is  more  serious,  how- 
ever, in  women,  for  it  is 
apt  to  produce  a  miscar- 
riage. After  the  subsi- 
dence of  an  attack,  a  swollen,  thickened,  or  cystic  appendix  may  sometimes 
be  felt.  Sometimes  also  there  may  be  present  for  some  weeks  a  roll  of 
thickened  adherent  omentum  which  may  closely  simulate  the  appendix  in 
size  and  shape. 

The  tendency  to  recurrence  is  so  strong,  that  a  certain  class  of  case  is 
often   termed  relapsing   perityphlitis.     A   recurrence,  has  been  variously 


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Fig.  93. 


estimated  as  occurring  in  from  23  to  44  per  cent.  In  some  instances, 
by  no  means  uncommon,  one  attack  succeeds  another,  with  very  short 
intervals  of  health.  Fifty  attacks  have  been  said  to  occur  in  eight  years, 
and  twelve  attacks  in  one  year.  The  individual  attacks  do  not  differ  from 
the  simple  perityphlitis  already  described,  but,  as  a  rule,  they  tend  to 
become  less  severe  as  time  goes  on.  On  the  other  hand,  it  must  be 
remembered  that  any  one  of  them  may  end  in  suppuration,  or  may  take 


DISEASES  OF  THE  INTESTINES. 


741 


the  form  of  a  general  peritonitis,  which  is  very  commonly  fatal.  The 
states  of  the  appendix  which  are  most  commonly  associated  with  the 
relapsing  perityphlitis  are  a  cystic  condition  and  a  chronic  catarrh.  Less 
commonly  a  concretion  is  found  to  be  present. 

Perityphlitic  abscess. — As  in  the  case  of  simple  perityphlitis,  so  in 
the  case  where  an  abscess  is  formed,  the  onset  of  symptoms  is  in  a  small 
proportion  of  instances  immediately  preceded  by  a  history  of  an  indi- 
gestible meal,  a  direct  injury,  or  a  strain.  The  early  symptoms,  moreover, 
in  the  two  conditions  of  simple  and  suppurative  perityphlitis  are  identical, 
and  during  the  first  few  days  it  is  impossible  to  foresee  whether  the 
illness  will  run  the  simple  course,  or  whether  an  abscess  will  arise  around 
the  appendix.  So  that  in  all  cases  presenting  the  symptoms  which  have 
been  detailed,  as  indicating  local  peritonitis  in  the  right  iliac  fossa,  the 
attention  must  be  directed  to  the  possibility  of  the  formation  of  an 
abscess  in  this  position,  and  to  its  early  recognition. 

If  the  patient  is  seen  for  the  first  time  at  the  end  of  the  first  week, 
or  later,  it  may  be  impossible  to  determine  at  one  interview  whether 
pus  is  present  or  not,  because  its  recognition  rests  not  so  much  on  any 


Hay  0/ 
Disease 

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Fig.  94. 

specific  physical  signs  or  symptoms  as  on  a  careful  observation  of  the 
whole  course  of  the  illness.  The  signs  by  which  the  presence  of  an 
abscess  is  recognised  elsewhere  are  commonly  absent  in  the  case  of  a 
perityphlitic  abscess.  There  is  usually  no  redness  of  the  skin  and  no 
oedema,  except  in  cases  of  long  standing,  and  fluctuation  cannot  be  de- 
tected save  sometimes  under  an  anaesthetic.  Similarly,  rigors  are  seldom 
if  ever  met  with.  The  diagnosis  of  abscess  formation  must  depend  on 
the  daily  observation  of  the  inflammatory  mass  in  the  groin,  of  the  tem- 
perature, and  of  the  general  condition. 

As  regards  the  first  point,  evidence  of  pus  is  afforded  either  by  the 
maintenance  of  the  inflammatory  mass  unaltered  for  an  unusual  period 
of  time,  or  by  the  occurrence  of  a  further  increase  in  its  size  after  the 
first  few  days  of  the  illness,  or  a  further  increase  in  its  tenderness.  The 
larger  and  the  harder  is  the  tumour,  the  more  likely  is  it  to  contain  pus. 
As  a  rule,  in  simple  perityphlitis,  the  mass,  having  attained  the  maximum 
;size  in  the  first  week,  remains  stationary  for  a  day  or  two,  losing  its 
tenderness,  and  then  begins  to  subside.  As  regards  the  second  point, 
-an  important  indication    of   suppuration  is    an    unusual    continuance    of 


742  ALIMENTARY  SYSTEM. 

high  fever,  or  a  secondary  rise  of  temperature  after  a  fall  has  set  in. 
(Fig.  94).  It  must  be  remembered,  however,  that  both  these  events  may 
sometimes  occur  in  a  simple,  non-suppurative  case.  Finally,  evidence 
must  be  obtained  from  the  condition  of  the  tongue,  from  the  appetite, 
from  the  frequency  of  the  pulse,  and  from  the  appearance  and  feelings  of 
the  patient. 

By  a  consideration  of  all  these  points  taken  together,  the  presence 
of  an  abscess  can  usually  be  recognised  at  an  early  period,  in  cases  that 
have  been  watched  throughout  their  whole  course.  At  the  same  time,  it 
must  be  remembered  that  the  danger  of  rupture  into  the  general  peri- 
toneal cavity  of  an  abscess,  which  remains  unopened,  is  extremely  slight 
if  the  patient  is  under  careful  treatment  in  bed.  And  under  these  con- 
ditions, a  delay  of  a  day  or  two  in  opening  the  abscess  is  of  no  great 
importance,  as  the  protective  intestinal  adhesions  which  surround  it  are 
of  considerable  strength.  The  most  certain  indications  of  an  abscess  in  the 
course  of  the  second  week  of  the  illness  are  given  by  the  continuance  of  a 
large,  hard,  tender  mass,  the  absence  of  a  fall  in  the  temperature,  or  the 
presence  of  a  secondary  rise,  the  continuance  of  a  quick  pulse,  and  of  a 
furred  tongue. 

The  abscess  varies  much  in  size,  but  it  commonly  contains  from  2  to  4  oz. 
of  pus.  The  inflammatory  mass  in  the  groin  is  often  the  size  of  a  man's  fist, 
but  it  may  be  much  larger.  It  may  extend  upwards  nearly  to  the  right 
costal  margin,  or  inwards  across  the  middle  line.  Its  cavity  has  usually 
the  abdominal  wall  for  a  roof,  and  the  caecum,  and  iliacus  or  psoas  for 
a  floor,  with  a  wall  of  adherent  bowel  on  the  left.  If  it  is  small,  how- 
ever, there  may  be  small  intestine  between  it  and  the  abdominal  wall, 
and  the  pus  is  deeply  placed  alongside  of  the  caecum.  The  cavity  often 
has  one  or  more  processes  which  run  in  various  directions,  especially  into 
the  pelvis  among  the  adherent  intestinal  coils.  If  the  appendix  dips  into 
the  pelvis,  a  resulting  abscess  may  lie  entirely  below  the  brim  of  the 
pelvis.  In  such  a  case  it  may  happen  that  it  can  be  felt  only  on  examina- 
tion by  rectum  or  vagina,  and  diagnosis  may  be  very  difficult.  In  women 
it  often  cannot  be  distinguished  from  the  result  of  disease  of  the  uterine 
appendages.  It  is  possible  also  that  in  the  case  of  a  retrocecal  a.ppendix 
an  abscess  may  be  developed  in  the  flank,  or  even  high  up  under  the 
right  costal  margin.  A  subphrenic  abscess  may  be  found,  and  there  is- 
then  some  risk  that  the  diaphragm  may  be  perforated,  and  a  suppurative 
pleurisy  developed.  Cases  have  also  occurred  wrhere,  owing  to  the  free- 
dom and  unusual  position  of  the  caecum,  an  abscess  has  been  formed 
elsewhere  in  the  abdomen,  for  the  most  part  under  the  left  rectus  at  the 
level  of  the  umbilicus. 

Finally,  it  must  be  mentioned  that  if  the  appendix  is  adherent  to  the 
iliacus -peritoneum,  a  perforation  of  it  on  the  adherent  side  may  lead 
directly  to  inoculation  of  and  suppuration  in  the  retroperitoneal  tissue. 
And  it  may  happen  that  in  cases  of  long-standing  perityphlitic  abscess- 
the  ihacus-peritoneum  may  become  secondarily  necrosed  and  perforated. 
In  either  case,  the  pus  gains  entrance  to  the  retroperitoneal  tissue,  and 
may  burrow  widely  in  it,  baring  the  ilium,  passing  down  into  the  thigh 
along  the  psoas,  and  even  entering  the  hip-joint. 

Certain  complications  may  ensue  in  a  case  of  perityphlitic  abscess.  A 
general  peritonitis  may  be  set  up  by  rupture  or  leakage  of  the  abscess,. 
due  to  some  movement  of  the  patient,  and  this  is  most  likely  to  occur  at- 
an  early  stage,  when  the  protecting  adhesions  are  soft.     After  the  opening 


DISEASES  OF  THE  INTESTINES.  743 

of  an  abscess,  fecal  matter  may  appear  in  the  discharge  for  several  days, 
and  there  is  doubtless  a  communication  either  with  the  appendix  or  with 
the  caecum.  This  in  nearly  all  cases  soon  closes,  and  no  operative  inter- 
ference is  advisable.  The  abscess,  if  neglected,  may  discharge  spon- 
taneously into  the  caecum,  or  possibly  into  the  rectum,  and  the  result  is 
not  unfavourable.  It  may  also  open  into  the  bladder,  or  through  the 
abdominal  wall.  A  fatal  haemorrhage  has  been  known  to  occur  from 
ulceration  into  an  iliac  artery  after  the  opening  of  an  abscess.  An 
abscess  in  the  liver  may  result,  usually  in  long-standing  cases,  through  an 
infective  thrombosis  of  some  radicle  of  the  portal  vein,  either  in  the 
appendix  itself,  or  more  commonly  in  some  part  of  the  intestine  which 
enters  into  the  composition  of  the  wall  of  the  abscess  cavity.  The 
hepatic  abscess  is  usually  single,  as  in  dysentery,  and  is  amenable  to 
surgical  treatment,  but  sometimes  a  typical  pylephlebitis  results  with  the 
formation  of  ramifying  channels  of  suppuration  throughout  the  whole 
organ.  The  occurrence  of  intestinal  obstruction  by  adhesions  as  a  sequela 
of  perityphlitis,  simple  or  suppurative,  is  described  elsewhere. 

The  prognosis  in  a  case  of  perityphlitic  abscess  in  the  iliac  fossa  is 
extremely  favourable  if  it  is  dealt  with  at  an  early  period;  but  death 
occurs — perhaps  in  as  many  as  20  per  cent,  of  the  cases — either  from 
neglect  of  the  abscess,  or  from  the  difficulty  of  diagnosis  and  treatment, 
when  it  is  situated  in  an  unusual  position,  or  from  some  one  of  the  com- 
plications mentioned. 

General  peritonitis. — The  onset  of  symptoms  is,  as  a  rule,  sudden  and 
severe  from  the  first,  and  in  only  a  small  proportion  of  cases  is  there  any 
previous  history  pointing  to  appendicitis.  The  signs  and  symptoms  are 
for  the  most  part  identical  with  those  of  general  peritonitis  from  other 
causes.  There  is  a  sudden  onset  of  severe  pain  across  the  lower  part  of 
the  abdomen,  which  is  seldom  more  marked  in  the  right  iliac  fossa 
than  elsewhere.  Vomiting  occurs  commonly  within  a  few  minutes  or 
hours. 

If  the  patient  is  seen  within  the  first  few  hours,  it  is  often  impossible  to 
recognise  the  true  nature  of  the  case,  though  the  occurrence  of  a  con- 
tinuous abdominal  pain  with  vomiting  will  always  suggest  the  precaution 
of  keeping  the  patient  completely  at  rest.  But  during  the  first  twenty-four 
hours  the  pain  and  vomiting  continue,  and  perhaps  increase  in  severity. 
The  pain  is  constant,  and  not  paroxysmal ;  the  abdomen,  which  is  acutely 
tender  becomes  more  and  more  distended,  and  ceases  to  be  moved  during 
respiration.  The  temperature  rises,  and  may  reach  102°  or  103°.  The 
pulse  is  much  quickened,  the  mouth  and  lips  become  dry,  and  the  tongue 
is  furred.  The  patient  commonly  lies  on  his  back,  with  his  knees 
drawn  up.  Before  the  second  day  is  passed,  the  condition  is  usually 
clear.  The  pain  and  vomiting  continue,  though  they  may  abate  or  cease 
under  the  influence  of  opium.  Hiccough  is  sometimes  distressing.  The 
abdomen  becomes  more  and  more  distended,  and  is  absolutely  motionless 
and  very  tender.  It  is  often  resonant  in  all  parts,  but  in  some  cases  at  a 
later  stage  there  is  evidence  of  fluid  in  the  flanks,  and  possibly  elsewhere. 
The  veins  running  down  to  the  groins  may  become  visible.  Thirst  and 
dryness  of  the  mouth  are  distressing.  The  pulse  is  quick  throughout,  and  be- 
comes more  and  more  feeble.  The  urine  is  scanty,  and  may  contain  albumin. 
There  is  often  some  pain  in  micturition,  owing  to  the  contraction  of  the 
bladder,  of  which  the  peritoneal  surface  is  inflamed,  and  the  use  of  a 
catheter  is  sometimes  necessary.       The  bowels  usually  cease  to  act  from 


744  ALIMENTARY  SYSTEM. 

the  first.  The  face  is  pinched  and  worn,  and  the  eyes  are  sunken.  As 
time  goes  on,  the  temperature  may  fall  and  may  be  normal  or  subnormal. 
The  patient  grows  apathetic.  The  hands  are  cold  and  the  forehead  moist, 
the  pulse  can  no  longer  be  counted,  and  death  occurs  commonly  about  the 
end  of  the  first  week,  though  it  is  sometimes  earlier  by  a  day  or  two,  and 
may  be  postponed  for  another  week.  Though  death  is  the  usual  result, 
a  small  minority  of  cases,  presenting  all  the  signs  and  symptoms  above 
detailed,  end  favourably.  In  many  of  these,  as  the  general  abdominal 
distension  and  tenderness  pass  off,  some  indication  of  an  inflammatory  mass 
can  be  felt  in  the  right  iliac  fossa. 

Certain  variations  in  the  onset  and  course  of  the  illness  are  to  be  noted. 
In  the  first  place,  the  onset  may  be  gradual.  The  early  symptoms  are 
then  of  less  severity,  they  are  in  fact  not  to  be  distinguished  from  those 
already  detailed  as  occurring  in  a  simple  perityphlitis,  and  they  may  give 
rise  to  no  anxiety.  But  they  assume  increased  severity  after  the  lapse  of 
a  few  days,  and  a  general  peritonitis  is  rapidly  developed,  which  will  run 
the  commonly  fatal  course.  Such  cases  do  certainly,  though  rarely,  occur, 
even  when  the  patient  has  been  presumably  kept  in  bed  from  the  first, 
but  they  usually  arise  through  a  want  of  appreciation  of  the  real  gravity 
of  the  early  symptoms,  or  through  an  attempt  on  the  part  of  the  patient 
to  keep  about  or  continue  at  work.  In  the  next  place,  collapse  may  take 
place  with  surprising  suddenness  early  in  the  illness,  and,  in  the  course  of 
a  few  hours,  a  patient  whose  condition  up  to  that  time  is  not  unfavourable 
may  pass  the  point  at  which  an  operation  can  be  undertaken.  Finally,  in 
some  cases,  a  general  peritonitis  is  suddenly  developed  by  the  rupture  or 
leakage  of  a  localised  perityphlitic  abscess,  which  may  have  been  a  week 
or  more  in  existence.  Such  an  accident,  though  decidedly  uncommon,  has 
been  known  to  occur  during  the  removal  of  a  patient  from  his  home  to  a 
hospital. 

Prognosis. — In  a  simple  perityphlitis  recovery  is  invariable.  In 
perityphlitic  abscess  the  mortality  rate  is  about  20  per  cent.,  but  there 
can  be  little  doubt  that  this  admits  of  considerable  reduction.  In  general 
peritonitis  of  appendicular  origin  the  mortality  is  very  high,  but  even 
here  a  successful  result  after  operation  is  becoming  more  common.  The 
general  mortality  of  all  forms  of  peritonitis,  due  to  disease  of  the  appendix, 
may  be  placed  at  10  to  12  per  cent. 

Treatment. — A  correct  treatment  of  appendicitis  and  the  resulting 
peritonitis  can  be  based  only  on  a  correct  appreciation  of  the  nature  and  ex- 
tent of  the  changes  which  are  taking  place  from  day  to  day  in  the  peritoneal 
cavity.  Upon  the  appearance  of  the  symptoms  that  have  been  detailed  as 
marking  the  beginning  of  inflammation  of  the  peritoneum,  the  patient 
must  from  that  moment  be  confined  to  his  bed,  and  arrangements  must 
be  made  which  shall  obviate  his  rising  for  the  calls  of  nature.  The  diet 
should  consist  mainly  of  milk  diluted  with  soda-water,  and  beef-tea,  meat- 
jelly,  or  the  like.  A  grain  of  opium  in  a  pill,  or  a  quarter  of  a  grain  of 
morphine  subcutaneously,  may  be  given  to  an  adult,  and  may  be  repeated 
in  four  hours'  time.  But  it  is  of  importance  to  be  sparing  in  the  use  of 
opium,  for  the  effect  is  often  to  produce  a  great  though  temporary  improve- 
ment in  the  appearance  and  feelings  of  the  patient,  so  that  it  is  difficult 
to  form  that  correct  idea  of  his  real  condition  upon  which  proper  treat- 
ment must  be  based.  Hot  fomentations  or  an  ice-bag  will  be  found  to 
give  some  relief  from  the  pain. 

From    the    early   symptoms  it    is    often   impossible    to    foresee    what 


DISEASES  OF  THE  INTESTINES.  745 

degree  of  peritonitis  will  result,  whether  it  will  be  localised  in  the  right 
iliac  fossa  or  will  become  generalised ;  and,  as  has  been  already  mentioned, 
the  first  pain,  even  in  a  mild  case  of  simple  perityphlitis,  is  often  felt 
as  widely  diffused  over  the  abdomen  as  in  a  general  peritonitis.  But 
sometimes  from  the  first,  and  generally  during  the  first  twenty-four  or 
thirty-six  hours,  it  can  be  determined  with  certainty  whether  the  peri- 
tonitis will  be  local  or  general,  and  the  further  treatment  will  vary  in  the 
two  cases. 

Local  peritonitis. — The  diet  must  be  fluid  and  light  until  a  day  or 
two  after  the  temperature  has  become  normal,  and  it  may  then  be 
gradually  increased  in  variety.  The  pain  can  be  relieved  to  some  extent 
by  warmth  or  cold,  and  four  or  six  leeches  for  an  adult  applied  over  the 
right  groin  will  often  prove  of  great  service.  Opium  must  usually  be 
employed  at  first,  but  its  use  must  be  sparing,  and  it  must  be  discontinued 
as  soon  as  possible.  The  patient  must  be  kept  in  bed,  at  any  rate  until 
several  days  after  the  disappearance  of  all  tenderness  and  fever.  No 
attempt  should  be  made  to  procure  an  action  of  the  bowels  until 
evidence  of  the  subsidence  of  the  inflammation  is  perceived  and  it  is 
always  well  to  err  on  the  side  of  constipation.  At  first,  a  glycerin  or 
simple  enema  must  be  used,  and  no  purgative  should  be  given  until  the 
patient  is  well  enough  to  leave  his  bed.  During  convalescence  an 
occasional  small  dose  of  castor-oil  or  some  mineral  water  is  often  required, 
and  if  mucus  is  found  in  the  stools  it  may  be  well  to  give  salol  (15  grs. 
a  day)  for  a  week  or  so.  For  the  rest,  it  is  important  that  for  some 
months  the  patient  should  not  take  any  violent  exercise,  should  be  careful 
in  his  diet,  and  should  not  allow  the  bowels  to  become  constipated. 

All  through  the  conduct  of  the  case,  the  possibility  of  the  formation  of 
pus  must  be  kept  in  mind.  If  the  case  is  methodically  observed  from  the 
first,  there  is  usually  little  difficulty  in  recognising  abscess  formation.  An 
abscess  must  be  opened  as  soon  as  it  is  certainly  recognised,  but  in  cases 
of  doubt  it  must  be  remembered  that  a  delay  of  a  day  or  two  in  the  case 
of  a  patient  who  is  under  skilled  treatment  and  nursing,  is  attended  with 
no  appreciable  risk.  When  a  perityphlitic  abscess  has  been  dealt  with, 
and  has  healed,  it  is  exceedingly  rare  for  any  further  trouble  to  develop 
in  connection  with  the  appendix.  A  second  abscess,  however,  has  been 
known  to  occur  after  the  lapse  of  three  years. 

On  the  other  hand,  after  an  attack  of  simple  perityphlitis,  subsequent 
attacks  are  very  likely  to  occur,  and  a  recurrence  has  been  variously 
estimated  as  occurring  in  from  23  to  44  per  cent.  In  many  cases  a  long 
series  of  attacks  will  occur,  so  that  the  patient  is  more  or  less  incapacitated 
for  work  or  play,  and  he  may  become  a  confirmed  invalid.  While  the 
attacks  in  such  a  case  usually  tend  to  become  less  and  less  severe,  it  must 
be  remembered  that  any  one  of  them  may  prove  fatal.  Consequently,  on 
the  ground  of  preventing  the  great  loss  of  time  and  the  slight  loss  of  life 
that  is  entailed  by  a  recurrence  of  attacks,  excision  of  the  appendix  should 
be  recommended  to  the  patient  after  the  first  attack.  The  risk  attending 
the  operation  is  very  slight.  The  most  favourable  opportunity  for 
operation  is  the  time  when  all  fever  and  general  symptoms  have  subsided, 
and  the  right  iliac  fossa  is  free  from  tenderness. 

It  is  not  possible  to  foresee  in  any  individual  case  whether  an  attack 
will  be  a  solitary  one  or  the  first  of  a  long  series,  and  consequently  it  may 
be  thought  advisable  to  wait  for  a  second  attack  before  recommending 
excision.     But  it  must  be  remembered  that  every  attack  tends  to  leave 


746  •  ALIMENTARY  SYSTEM. 

adhesions  around  the  appendix,  and  in  some  cases  the  appendix  becomes 
so  firmly  bound  down  that  its  removal  cannot  be  carried  through  with 
safety.  Indications  which  should  more  particularly  point  to  operation 
after  a  first  attack  are  the  presence  of  a  tangible  enlarged  appendix  and 
the  possibility  of  the  occurrence  of  pregnancy. 

General  peritonitis. — The  feeding  and  management  of  a  patient  in 
whom  the  peritonitis  is  becoming  or  has  become  generalised,  are  of  great 
importance,  but  do  not  need  any  special  description.  Although  some  few 
cases  recover  without  operation,  even  when  the  peritonitis,  as  judged  by  the 
physical  signs,  must  be  said  to  be  general,  yet  in  the  majority  of  instances 
immediate  operation  affords  the  only  hope  of  saving  the  patient,  and  it 
should  be  undertaken  at  once  in  all  cases.  The  abdomen  must  be  opened 
in  the  middle  line,  and  also  over  the  right  iliac  fossa,  and  an  attempt  must 
be  made  to  excise  the  appendix,  and  at  any  rate,  by  flushing  all  parts  of 
the  peritoneal  surface,  to  remove  the  inflammatory  products  which  are 
teeming  with  micro-organisms.  Even  when  this  is  carried  out  at  the 
earliest  moment,  as  thoroughly  as  possible,  the  mortality  will  still  remain 
very  high.  There  may  be  numbers  of  centres  of  infection  or  small 
collections  of  pus  lying  between  the  intestines  in  all  parts  of  the  abdominal 
cavity,  and  after  the  most  thorough  flushing  many  of  them  will  remain 
untouched. 

H.  P.  HAWKINS. 


DISEASES   OF   THE   LIVER. 

The  liver  of  an  adult  weighs  about  ^  of  the  weight  of  the  whole  body ; 
at  birth  it  is  relatively  larger,  and  weighs  fa.  It  has  five  surfaces.  The 
anterior  lies  underneath  the  ribs,  and  is  entirely  covered  by  peritoneum, 
except  for  the  narrow  strip  between  the  two  layers  of  the  falciform  ligament. 
The  superior  surface  is  moulded  to  the  diaphragm,  and  has  on  it  a  shallow 
concavity  corresponding  to  the  position  of  the  heart.  The  posterior  surface 
merges  into  the  inferior ;  such  of  it  as  occupies  the  left  lobe  abuts  upon  the 
lesser  curvature  of  the  stomach ;  the  rest  of  this  surface  is  occupied  by, 
from  left  to  right,  the  Spigelian  lobe,  which  is  opposite  the  tenth  and 
eleventh  dorsal  vertebrae,  the  depression  for  the  inferior  vena  cava,  and 
most  to  the  right  a  strip  of  2 \  to  3  in.  broad,  which  is  uncovered 
by  peritoneum,  and  rests  against  the  ascending  part  of  the  diaphragm,  and 
has  on  it  a  slight  depression  formed  by  the  right  suprarenal  capsule.  The 
inferior  surface  looks  downwards,  backwards,  and  to  the  left.  The  part  of 
it  formed  by  the  left  lobe  is  moulded  over  the  stomach.  Passing  from  this 
to  the  right  we  find  the  quadrate  lobe,  which  is  in  contact  with  the  pylorus 
and  the  first  part  of  the  duodenum ;  next  to  the  right  we  meet  the  gall 
bladder ;  and  the  large  portion  of  the  inferior  surface  to  the  right  of  this 
is  in  contact  anteriorly  with  the  hepatic  flexure  of  the  colon  and  posteriorly 
with  the  right  kidney.  The  right  surface  lies  in  contact  with  the  right 
lateral  wall  of  the  abdomen. 

The  liver  occupies  the  right  hypochondriac  and  epigastric  regions,  and 
often  extends  into  the  left  hypochondriac  and  right  lumbar.  On  deep 
inspiration  in  thin  people,  whose  abdominal  muscles  are  lax,  the  lower  edge 
of  the  right  lobe  between  the  anterior  and  under  surfaces  can  be  felt  by 
the  fingers  to  descend,  if  they  are  thrust   up   under  the   ribs.      In  the 


DISEASES  OF  THE  LIVER.  747 

epigastric  angle  a  small  portion  of  the  anterior  surface  of  the  left  lobe 
conies  in  contact  with  the  anterior  abdominal  wall,  but  it  usually  cannot 
be  felt  owing  to  the  rigidity  of  the  rectus.  Except  for  this,  the  liver 
is  everywhere  separated  from  the  surface  by  the  ribs.  Symington 
gives  its  relations  as  follows :  The  right  surface  is  protected  by 
the  seventh  to  eleventh  ribs,  the  anterior  surface  by  the  fifth  to 
ninth  costal  cartilages,  by  the  anterior  parts  of  the  corresponding  ribs, 
and  by  the  ensiform  cartilage,  the  diaphragm  being  of  course  interposed. 
The  upper  limit  may  be  indicated  by  a  line  which  crosses  at  the  lower  end 
of  the  body  of  the  sternum.  To  the  left,  this  line  passes  horizontally ;  to 
the  right,  it  ascends  slightly,  so  that  in  the  nipple  line  it  is  near  the  upper 
border  of  fifth  rib ;  from  this  point  it  descends  to  the  seventh  rib  in  the 
mid-axillary  line.  The  lower  limit  of  the  liver  corresponds  with  the  lower 
margin  of  the  right  ribs,  as  far  towards  the  middle  line  as  the  tip  of  the 
ninth  right  costal  cartilage ;  it  then  passes  upwards  and  to  the  left  to 
near  the  tip  of  the  eighth  left  costal  cartilage,  and  it  is  then  continued 
upwards  and  to  the  left  till  it  meets  the  upper  limit  at  an  acute  angle. 
The  precise  relationship  of  the  liver  to  the  abdominal  wall  varies  slightly 
in  health,  for  the  organ  is  often  a  little  lower  in  the  erect  than  the 
horizontal  posture,  and  it  descends  on  inspiration  and  ascends  on 
expiration. 

It  is  clear  that  much  lung  intervenes  between  the  liver  and  the  skin, 
and  it  is  often  of  importance  to  remember  that  posteriorly  the  thin  lower 
border  of  the  lung  does  not  reach  lower  than  the  tenth  rib,  so  that  below 
the  tenth  rib  the  costal  and  diaphragmatic  portions  of  the  pleura  are  in 
contact ;  and  that  the  inferior  limit  of  the  pleura  does  not  quite  extend  to 
the  attachment  of  the  diaphragm,  but  leaves  a  small  portion  of  the  circum- 
ference of  this  muscle  in  contact  with  the  costal  parietes. 

The  hepatic  dulness  to  the  left  of  the  sternum  cannot  be  distinguished 
from  that  due  to  the  heart.  On  the  right  it  begins  at  the  end  of  the  body 
of  the  sternum  ;  in  the  nipple  line  it  reaches  the  fifth  intercostal  space,  in 
the  mid-axillary  the  seventh,  and  in  the  line  of  the  angle  of  the  scapula  the 
ninth,  but  its  limit  at  the  back  is  often  difficult  to  determine  precisely. 
In  trying  to  settle  whether  the  liver  is  enlarged,  it  should  be  remembered 
that  in  children  it  is  proportionately  larger  than  in  adults  ;  that  when  the 
chest  is  deformed  from  rickets  or  curvature  of  the  spine,  the  liver  descends 
lower  than  in  health ;  that  it  may  be  thrust  down  considerably  in  women 
by  tight-lacing,  and  in  men  by  the  practice  of  wearing  a  belt ;  or  by  ex- 
tensive pleuritic  or  pericardial  effusion  ;  or  by  collections  of  fluid  between 
the  liver  and  diaphragm  or  in  the  substance  of  the  diaphragm ;  and,  lastly, 
in  that  rare  condition  known  as  Glenard's  disease  the  liver  may  in  the  erect 
posture  descend  considerably.  Tight-lacing  may  furrow  it  so  deeply  that 
the  furrow  can  be  felt  during  life.  Ascites  and  any  very  large  abdominal 
tumour  may  press  the  liver  up  so  that  the  hepatic  dulness  is  raised,  and  Mur- 
chison  has  recorded  a  case  in  which  the  liver  passed  into  the  chest  through 
a  congenital  hole  in  the  diaphragm.  Extensive  emphysema  or  a  collection  of 
gas  in  the  abdominal  cavity,  such  as  occurs  after  perforation  of  the  stomach, 
may  obliterate  the  hepatic  dulness.  Various  abdominal  tumours  may 
cause  the  liver  to  appear  larger  than  it  really  is.  When  this  deception 
arises  from  a  mass  in  the  omentum  (and  this  is  the  commonest  cause),  the 
edge  of  the  liver  can  usually  be  made  out  apart  from  the  tumour,  and  a 
narrow  line  of  resonance  often  intervenes  between  the  two.  Masses  of 
faeces  in  the  colon,  and  tumours  of  the  stomach  and  of  the  kidney,  may  also 


748  ALIMENTARY  SYSTEM. 

cause  difficulty;  and  any  of  these  abdominal  tumours  may  from  their 
attachment  to  the  liver  move  during  respiration.  Confusion  sometimes 
arises,  because  the  colon  gets  in  front  of  the  liver.  Lastly,  tumours  of  the 
abdominal  wall  may  lead  to  error. 

The  reflected  pain  and  cutaneous  tenderness  due  to  disease  of  the  liver 
are  not  as  a  rule  referred  so  distinctly  to  definite  cutaneous  areas,  as  they 
may  be  when  other  organs  are  diseased ;  but  Head  considers  that  the  eighth 
and  ninth  dorsal  segments  on  both  sides,  and  the  tenth  on  the  right,  corre- 
spond to  the  liver.  The  eighth  begins  at  the  back  opposite  the  ninth  and 
tenth  dorsal  spine,  and  the  ninth  opposite  the  eleventh  and  twelfth  ;  both 
extend  nearly  horizontally  round,  so  that  the  lower  margin  of  the  ninth  is 
at  the  umbilicus.  The  posterior  maximum  points  of  tenderness  of  each  is 
almost  vertically  below  the  vertebral  border  of  the  scapula,  the  anterior 
maximum  point  of  the  ninth  is  just  over  the  gall  bladder,  and  that  of  the 
eighth  is  just  above  it.  The  tenth  dorsal  area  is  rather  a  wide  one,  lying 
below  the  ninth.  The  cephalic  areas  associated  with  these  are  the  occipital, 
associated  with  the  tenth ;  the  parietal,  with  the  ninth  ;  the  vertical,  which 
is  on  the  scalp  just  in  front  of  and  above  the  ear,  with  the  eighth ;  and 
in  hepatic  disorders,  headache  and  cutaneous  tenderness  may  be  present 
in  these  areas.  In  cases  of  gallstones  and  disease  of  the  gall  bladder,  the 
reflected  pains  and  cutaneous  tenderness  are  often  very  well  marked, 
especially  over  the  eighth  and  ninth  dorsal  areas,  but  the  fifth,  sixth,  and 
seventh  are  as  a  rule  implicated  more  or  less. 

JAUNDICE. 

Etiology. — Saunders  showed,  at  the  end  of  the  last  century,  that 
jaundice  could  be  produced  by  ligature  of  the  bile  duct ;  and  even  now  the 
only  form  of  jaundice  we  understand  is  that  in  which,  owing  to  partial  or 
complete  obstruction  to  the  flow  of  bile  through  the  ducts,  the  rise  in 
pressure  behind  the  obstruction  leads  to  an  absorption  of  the  bile — partly 
by  the  veins,  but  chiefly  by  the  lymphatics — into  the  blood,  from  which 
it  passes  with  the  plasma  into  the  tissues,  which  it  stains.  This  is  called 
obstructive  jaundice  ;  its  causes  are  as  follow : — 

A.  Obstruction  within  the  ducts  outside  the  liver— 

1.  Gallstones.     This  is  one  of  the  most  common  causes  of  jaundice. 

2.  Cancer  of  bile  ducts  \ 

3.  Cicatrix  from  a  heated  ulcer  \  Yery  rare. 

4.  Congenital  obliteration  J 

5.  Hydatid  ruptured  into  the  bile  duct  \ 

6.  Ascaris  lumbricoides  I    Mere  curiositieg- 

7.  Distoma 

8.  Foreign  bodies  passing  in  from  the  duodenum    J 

9.  Thickening  of  bile. — Probably  the  best  instance  of  jaundice  due  to 
this  is  that  seen  in  poisoning  by  tuluylendianrine,  which  greatly  increases 
the  consistency  of  the  bile,  and  it  is  supposed  that  it  becomes  so  thick  as 
really  to  obstruct  its  own  flow. 

10.  Swelling  of  the  mucous  membrane  from  inflammation. — In  this 
condition  it  is  possible  that  the  increased  secretion  of  mucus  thickens  the 
bile,  and  so  the  obstruction  caused  by  the  swollen  mucous  membrane  is 
increased.  So  strong  is  the  belief  that  the  condition  commonly  called 
simple  jaundice  is  due  to  inflammation  spreading  from  the  duodenum  into 


DISEASES  OF  THE  LIVER.  749 

the  bile  duct,  that  many  call  it  catarrhal  jaundice,  but  the  post-mortem 
evidence  of  catarrhal  inflammation  of  the  bile  ducts  is  very  scanty. 

11.  Spasm  of  the  ducts. — Severe  fright  or  shock  may  cause  jaundice,  and 
this  has  been  ascribed  to  a  spasm  of  the  duct. 

B.  Obstruction  from  pressure  en  ducts  outside  the  liver — 

1.  Enlargement  of  the  glands  in  the  transverse  fissure. — This  is  a  very 
common  cause  of  jaundice.  The  enlargement  is  nearly  always  due  to 
malignant  deposit,  usually  dependent  upon  growth  in  the  liver  or  gall 
bladder.  Lardaceous,  gummatous,  or  tuberculous  glands  in  the  transverse 
fissure  are  mere  curiosities. 

2.  Cancer  of  the  head  of  the  pancreas. — This  also  is  a  common  cause  of 
jaundice. 

3.  Growth  of,  or  faeces  in,  the  hepatic  flexure  of  the  colon 

4.  Enlargement  of  the  kidney 

5.  Floating  kidney 

6.  Aneurysm  of  hepatic  artery 

7.  Other  abdominal  aneurysms  \  Very  rare. 

8.  Peritoneal  bands,  thickenings,  or  tumours 

9.  Pregnant  uterus 

10.  Ovarian  or  uterine  tumours 

11.  Cicatrisation  of  a  duodenal  ulcer 

C.  Obstruction  -within  the  ducts  inside  the  liver — 

1.  Cancer  of  the  smaller  bile  ducts. 

2.  Thickening  of  the  bile. — Many  forms  of  jaundice  have,  on  the 
strength  of  experiments  with  toluylendiamine,  been  ascribed  to  this ;  and 
some  observers  suppose  that  whenever  the  obstruction  is  not  visible  to  the 
naked  eye,  as,  for  instance,  in  acute  yellow  atrophy,  yellow  fever,  pyaemia, 
pneumonia,  snake  poisoning,  phosphorus  poisoning,  cirrhosis  of  the  liver, 
jaundice  due  to  shock  or  fright  and  that  due  to  arterial  or  venous  con- 
gestion of  the  liver,  the  jaundice  is  really  obstructive,  the  obstruction  being 
the  thickened  bile  in  the  minute  ducts. 

3.  Hanot  has  suggested  that  some  of  the  varieties  of  jaundice  just 
mentioned  may  be  due  to  swelling  of  the  hepatic  cells ;  he  supposes  that 
certain  toxines  may  cause  this,  that  it  is  unlikely  that  the  swelling  will  be 
equal  in  all  the  cells,  that  if  the  cells  at  the  periphery  of  a  lobule  are  more 
swollen  than  those  at  the  centre,  the  pressure  of  bile  in  the  centre  of  the 
lobule  will  be  raised,  and  that  thus  we  shall  have  a  form  of  obstructive 
jaundice. 

D.  Obstruction  from  pressure  on  ducts  inside  the  liver — 

1.  Cancerous  or  sarcomatous  nodules  in  the  liver. 

2.  Abscess  in  the  liver. 

3.  Hydatids  in  the  liver. 

4.  Congestion  of  the  liver. — A  patient  suffering  from  a  nutmeg  liver, 
owing  to  disease  of  the  heart  or  lungs,  is  often  jaundiced,  and  it  has  been 
supposed  that  this  is  because  the  distended  veins  press  on  the  finer  bile 
ducts. 

5.  Cirrhosis. — It  is  possible  that  the  jaundice  in  this  condition  is  partly 
due  to  pressure  caused  by  the  contraction  of  the  new-formed  fibrous  tissue. 

It  has  been  thought  that  sometimes  jaundice  may  be  caused  by  the 
obstruction  to  the  flow  of  bile,  which  would  result  from  imperfect  respira- 
tory movements.     That  associated  with  pneumonia  might  be  due  to  this 


7  5  o  ALIMENTAR  Y  SYSTEM. 

cause,  but  it  is  probably  toxic.  It  will  be  seeu  from  the  above  list  that  it 
is  possible  to  explain  all  cases  of  jaundice,  on  the  supposition  that  they 
are  due  to  obstruction  to  the  egress  of  bile,  and  its  consequent  excessive 
reabsorption.  All  pathologists  admit  this  explanation,  when  the  obstruc- 
tion is  obvious  after  death,  and  many  think  no  other  form  of  jaundice  is 
possible.  But  other  explanations  have  been  suggested  for  those  cases  in 
which  the  obstruction  is  not  obvious. 

Some  suppose  that  the  process  of  secretion  is  at  fault.  Too  much  bile 
may  be  secreted,  or  it  may  contain  too  much  pigment,  or  some  abnormal 
pigments  which  are  easily  absorbed ;  and  it  is  further  supposed  that,  under 
these  conditions,  reabsorption  of  bile  may  take  place  in  the  ducts,  without 
any  increased  pressure  in  them,  or  it  may  take  place  from  the  intestine. 
Another  view  is  that  of  Liebermeister,  who  suggests  that  the  liver  cells 
may  be  diseased  in  such  a  way  that  they  cannot  sufficiently  rapidly 
excrete  all  the  bile  they  form,  and  so  some  of  it  is  reabsorbed  from  them. 

Many  believe  that  in  some  cases  jaundice  is  the  result  of  a  change  in 
the  blood.  Thoma  has  recently  supported  this  view.  Certain  persons,  he 
points  out,  can  separate  the  haemoglobin  from '  the  corpuscles ;  it  becomes 
free  in  the  blood ;  some  of  it  passes  out  in  the  urine  as  methsenioglobin ; 
and  another  part,  he  believes,  reaches  the  liver,  and  is  converted  into  bile 
pigment.  Thus  an  excess  of  bile  is  excreted,  this  excess  is  absorbed  from 
the  biliary  passages  and  intestines,  and  so  the  jaundice  exists.  He  also 
suggests  that,  in  some  cases,  bile  pigment  may  be  formed  in  the  tissues 
from  the  blood;  and  he  quotes  Neumann  as  saying  that  bile  pigment 
forms  in  blood  extravasated  into  the  tissues. 

Clinically  it  is  always  important  to  determine  whether  jaundice  is  due 
to  some  gross  obstruction  of  the  larger  ducts,  and  to  remember  that  nearly 
all  cases  of  jaundice  are  due  to  malignant  disease,  gallstones,  catarrhal 
jaundice,  or  cirrhosis. 

Symptoms. — In  health,  neither  bile  acids  nor  pigment  can  be 
demonstrated  in  the  blood,  although  they  are  probably  reabsorbed  from 
the  intestine.  The  failure  to  find  them  is  due  most  likely  to  their  rapid 
excretion  by  the  liver  and  kidneys.  "When,  however,  the  patient  is 
jaundiced,  they  are  present  in  the  blood,  and  they  produce  the  following 
symptoms,  the  first  mentioned  being  due  to  bile  pigments : — 

The  skin  is  yellow,  owing  to  the  staining  of  the  Malpighian  layer 
by  the  bile  pigment,  which  has  diffused  out  of  the  blood  vessels.  The 
tint,  which  often  appears  within  twenty-four  hours  of  the  onset  of  obstruc- 
tion, varies  from  a  faint  to  a  deep  bright  yellow ;  if  the  pigment  is  not 
quickly  reabsorbed  from  the  skin,  the  colour  gradually  becomes  deeper 
and  green,  until  it  is  finally  a  very  dark  olive ;  but  this  dark  tint  is  only 
attained  when  the  jaundice  is  obviously  obstructive,  and  has  lasted  some 
time.  All  jaundice  may  vary  in  intensity  from  day  to  day.  Slight 
jaundice  is  easily  confounded  with  the  tint  of  skin  often  seen  in  anaemia ; 
but  if  the  patient  is  genuinely  jaundiced,  the  conjunctivae  are  always 
stained,  but  care  must  be  taken  not  to  mistake  fat  in  them  for  bile  pigment. 
Slight  jaundice  cannot  be  detected  by  artificial  light.  The  yellowness  of 
the  skin  often  persists  long  after  the  cause  of  the  jaundice  is  removed ; 
this  is  probably  because  the  excess  of  bile  in  the  blood  is  .excreted  by  the 
liver,  and  reabsorbed  from  the  intestine.  The  visible  mucous  membranes 
are  rarely  stained,  but  the  tongue  may  be  slightly  yellow. 

The  urine  contains  a  considerable  amount  of  both  bile  pigments  and 
acids.     The  former  give  it  a  dark  yellow  tint  when  seen  by  transmitted, 


DISEASES  OF  THE  LIVER.  751 

and  a  green  lustre  when  seen  by  reflected,  light.  Any  froth  on  the  surface 
of  the  urine  is  bright  yellow.  The  usual  test  is  for  a  little  urine  on  a  white 
plate  to  be  allowed  to  come  in  contact  with  a  little  strong  nitric  acid ;  if 
bile  pigments  are  present,  the  colour  changes  at  the  line  of  contact, 
becoming  green,  blue,  violet,  red,  and  lastly  yellow.  If  to  some  nitric  acid 
in  a  test  tube  some  jaundiced  urine  be  added  slowly  with  a  pipette,  a  red 
layer  is  seen  at  the  line  of  junction,  and  above  it  green,  blue,  violet,  red, 
and  finally  green  layers.  These  tests  show  better  if  the  bile  pigment  be 
dissolved  out  of  the  urine  with  chloroform ;  but  a  delicate  test  for  the 
presence  of  bile  in  the  urine  is  much  wanted,  because  often  the  nitric  acid 
test  is  only  decisive  when  to  the  naked  eye  it  is  obvious  the  urine  con- 
tains bile.  Such  urine  frequently  stains  the  bedclothes  yellow. 
Pettenkofer's  test  is  recommended  for  bile  acids,  but  it  is  very 
unsatisfactory.  Clinically,  the  dark  urine  of  jaundice  has  to  be  carefully 
distinguished  from  that  in  which  the  coloration  is  due  to  drugs,  such  as 
santonin,  rhubarb,  or  senna. 

The  sweat  is  usually  uncoloured,  but  it  may  be  stained  a  little.  The 
saliva  is  never  coloured,  unless,  as  in  mercurialism,  the  secretion  is 
pathological.  The  tears  are  always  free.  The  milk  may  contain  bile 
pigment,  for  infants  have  been  known  to  become  jaundiced  when  at  the 
breast  of  a  jaundiced  woman.  As  a  rule  the  sputum  is  unstained,  but  if 
the  patient  have  pneumonia  or  bronchitis  it  may  be  yellow.  Ascitic  and 
pleuritic  fluids  are  often  jaundiced. 

The  following  symptoms  are  most  probably  due  to  the  presence  of 
hile  acids  in  the  blood.  Disintegration  of  the  red  corpuscles,  and  the 
presence  of  dissolved  haemoglobin  in  the  blood  increases  the  formation 
of  bile  pigment  by  the  liver,  and  thus  deepens  the  jaundice ;  the  blood 
destruction  often  leads  to  general  weakness  and  anaemia,  and  is  very 
likely  the  cause  of  great  liability  to  petechial  or  even  the  more  serious 
hsemorrhages  which  may  often  be  seen  in  cases  of  long-standing  jaundice. 
There  is  often  a  bitter  taste  in  the  mouth ;  this  is  perhaps  due  to  taurocholic 
acid.  Pruritus  may  be  very  distressing,  and  render  the  patient's  life 
unendurable.  It  usually  only  occurs  in  cases  in  which  the  bile  duct  is 
obstructed.  In  most  cases  the  only  remedy  is  the  subcutaneous  injection 
of  morphine.  The  rate  of  the  pulse  is  often  reduced ;  sometimes  it  is  as 
low  as  40,  30,  or  even  lower.  Cerebral  symptoms  are  not  rare  in  cases  of 
long-standing  jaundice,  and  they  often  close  the  scene.  The  most  common 
are  depression  of  spirits,  stupor,  and  coma,  and  the  patient  may  lie  in  a 
dull  lethargic  condition  for  days  or  weeks.  But,  as  in  the  last  case  under 
my  care,  he  may  have  acute  delirium,  wild  maniacal  excitement,  and  con- 
vulsions. Earely  he  sinks  into  a  typhoid  state.  Xanthopsy,  or  yellow 
vision,  is  very  rare.  I  have  only  once  met  with  it.  Possibly  it  is  due  to 
staining  of  the  media  of  the  eye. 

Certain  other  symptoms  do  not  obviously  fall  under  the  heading  of 
poisoning  by  either  bile  pigment  or  bile  acids.  When  the  bile  cannot 
reach  the  intestines,  the  bowels  are  constipated,  the  faeces  are  clay-coloured, 
contain  much  fat,  stink  horribly,  and  the  patient  suffers  from  indigestion 
and  flatulence.  Those  affected  with  jaundice  occasionally  suffer  from 
xanthelasma,  for  a  description  of  which  the  reader  is  referred  to  the 
chapter  on  diseases  of  the  skin.  Lichen  urticaria  and  boils  are  also 
mentioned  by  Murchison,  but  they  are  very  rare.  It  is  said  that  jaundice 
diminishes  the  glycogenic  function  of  the  liver,  and  this  may  help  to 
explain  the  wasting  seen  in  long-standing  cases. 


752  ALIMENTARY  SYSTEM. 

On  post-mortem  examination,  the  subcutaneous  tissues,  the  connective' 
tissues  generally,  and  the  liver,  are  deeply  stained.  The  kidneys,  muscles,, 
tendons,  bones,  pleura,  and  peritoneum  show  the  staining  less;  and  the 
brain,  spinal  cord,  nerves,  salivary  gland,  and  pancreas  do  not  show  it  at  all. 

In  certain  diseases,  such  as  catarrhal  jaundice,  acute  yellow  atrophy  of 
the  liver,  phosphorus  poisoning,  nervous  jaundice,  and  icterus  neonatorum, 
the  jaundice  is  so  striking  that  they  are  described  from  the  standpoint  of  it. 


CATAEEH  OF  THE  COMMON  DUCT. 

This  common  disease  is  named  from  its  most  prominent  symptom.. 
The  term  catarrhal  jaundice  has  been  applied,  on  the  supposition  that  there 
is  a  catarrhal  swelling  of  the  mucous  membrane  of  the  common  duct  at  its 
entry  into  the  duodenum,  and  that  it  becomes  obstructed  partly  by  the- 
swelling,  and  partly  by  a  plug  of  thick  mucus.  The  inflammation  is- 
supposed  to  spread  from  the  duodenum.  This  hypothesis  is  supported 
by  Dupre,  who  has  described  all  the  histological  characters  of  catarrhal 
inflammation  as  occurring  in  the  common  duct  in  catarrhal  jaundice. 
Osier,  too,  has  seen  a  plug  of  inspissated  mucus  filling  the  diverticulum  of 
Vater,  and  the  narrower  portion  of  the  duct  just  at  the  orifice,  but  it  must 
be  admitted  that  our  knowledge  of  the  cause  of  this  form  of  jaundice  is 
very  scanty.'  Probably,  if  there  is  any  catarrh,  it  is  due  to  a  micro- 
organism. On  this  view  catarrhal  jaundice  is  an  obstructive  jaundice,  but 
it  has  been  suggested  that  toxines  produced  by  gastro-intestinal  catarrh 
may  be  absorbed  by  the  portal  vein,  and  in  some  way  so  act  on  the  liver 
as  to  cause  the  jaundice. 

Etiology. — Usually  no  cause  can  be  assigned,  but  simple  jaundice 
may  follow  indigestion,  and  probably  is  often  consecutive  to  gastric  catarrh 
induced  by  indigestible  food.  It  is  much  commoner  in  the  young  than  the 
old,  and  according  to  some  is  frequent  in  the  autumn  and  spring. 
Occasionally  at  these  seasons  so  many  cases  may  be  seen,  that  they 
suggest  an  epidemic  influence,  and  sometimes  undoubted  epidemics  occur. 
Murchison  considers  that  simple  jaundice  may  be  a  symptom  of  secondary 
syphilis,  and  he  thinks  that  in  elderly  persons  it  may  be  due  to  gout ;  still 
it  is  very  important  for  the  student  to  remember  that  the  jaundice  of 
elderly  people  is  rarely  simple. 

Symptoms. — Any  of  the  symptoms  due  to  bile  circulating  in  the 
blood  may  be  present  in  catarrhal  jaundice.  The  discoloration  of  the 
skin  is  very  marked ;  it  is  bright  yellow,  but  never  dark  green.  Pruritis  is 
rarely  severe,  and  the  only  cerebral  symptom  is  a  feeling  of  intense 
depression.  The  motions  are  clay-coloured,  and  the  bowels  are  constipated. 
The  attack  is  usually  preceded  or  accompanied  by  symptoms_  of  gastric 
catarrh,  namely,  pain  and  epigastric  tenderness,  nausea,  vomiting,  loss  of 
appetite,  and  a  furred  tongue.  The  liver  may  be  a  little  enlarged  and 
tender,  and  the  gall  bladder,  being  distended,  may  be  easily  felt.  Very 
rarely  there  is  slight  pyrexia.  The  patient  commonly  only  feels  ill  for  a 
few  days  or  perhaps  a  week,  but  the  jaundice  is  slow  to  go,  and  some 
remains  after  the  patient  is  otherwise  quite  well ;  cases  are  indeed  recorded 
in  which  it  has  lasted  two  or  three  months.  The  disease  is  liable  to 
recur  in  the  same  patient,  but  usually  it  completely  disappears,  and  it  is 
never  fatal. 

Treatment. — The  patient  should  remain  in  bed  a  few  days.     His 


DISEASES  OF  THE  LIVER. 


753 


food  should  be  light  and  easily  digestible,  usually  farinaceous  articles  are 
to  be  preferred.  The  bowels  should  be  kept  open  once  a  day,  and  some 
mild  cholagogue  purge,  such  as  a  little  calomel  at  night,  followed  by  a 
sulphate  of  sodium  mineral  water  in  the  morning,  is  perhaps  the  best. 
Occasionally,  if  there  is  much  hepatic  pain,  hot  fomentations  are  soothing. 
Should  syphilis  or  gout  be  present,  the  patient  may  have  mercury  or 
colchicum. 

ACUTE  YELLOW  ATEOPHY. 

This  disease  is  rare,  but  is  apparently  commoner  here  than  in  America  ; 
for  Osier  has  never  seen  a  case,  while  I  have  come  across  four. 

Etiology. — Seventy  per  cent,  of  the  cases  occur  in  women,  and  of  these 
about  half  are  pregnant  when  the  disease  first  shows  itself.  Nearly  all  the 
patients  are  between  the  ages  of  20  and  40.  Perhaps  cirrhosis  of  the  liver 
predisposes  to  acute  yellow  atrophy.    The  affection  is  probably  of  toxic  origin. 

Morbid  anatomy. — The  size  of  the  liver  varies,  but  it  is  nearly 
always  atrophied ;  and  we  have  one  in  the  museum  at  Guy's  Hospital 
which,  in  the  recent  state,  weighed  only  19  oz.  That  of  the  last  case  under 
my  care  weighed  31  oz.,  and  somewhere  near  this  is  a  very  usual  weight. 
The  capsule  is  nearly  always  healthy.  The  liver  is  equally  diminished  in 
size  in  all  directions,  and  so  soft  and  flabby  that  it  easily  folds  on  itself. 
Looked  at  from  the  outside,  it  is  usually  of  a  dirty  greenish  colour ;  but 
on  section  three  kinds  of  large  patches  of  colour  are  seen— bright  yellow, 
deep  red,  and  the  ordinary  hepatic  colouring.  If  the  case  has  been  very 
short,  the  yellow  is  in  excess ;  if  the  patient  has  lived  longer  than  usual, 
the  red  is  more  extensive  ;  and  this,  taken  with  the  fact  that  the  red  parts 
may  apparently  shrink  and  cause  depressions  on  the  surface  of  the  organ, 
goes  to  show  that  they  represent  a  later  period  of  the  disease  than  the 
yellow.  Histologically,  the  yellow  parts  show  only  granular  debris,  the 
substance  of  the  liver  having  evidently  undergone  rapid  destruction.  In 
the  red  patches  there  is,  in  addition  to  these  changes,  some  increased 
fibrous  tissue  in  connection  with  the  vessels  around  the  lobule.  There  may 
be  a  slight  excess  of  fat,  and  there  are  many  crystals  of  leucin  and  tyrosin. 
Occasionally,  acute  yellow  atrophy  appears  to  follow  cirrhosis  of  the  liver, 
or  the  formation  of  gallstones.  The  muscles,  especially  the  heart,  and  the 
kidneys  are  in  a  state  of  fatty  degeneration,  and  the  tissues  may  be  stained 
yellow.  Haemorrhages  are  common.  Leucin  and  tyrosin  may  be  seen  in 
the  kidney. 

Pathology. — The  whole  behaviour  of  acute  yellow  atrophy  of  the 
liver  points  to  its  being  due  to  a  micro-organism.  Staphylococci,  strepto- 
cocci, the  B.  coli  communis,  and  a  diplococcus,  have  all  been  described  as 
being  present,  but  no  definite  micro-organism  has  yet  been  isolated. 

Symptoms. — To  obtain  a  conception  of  the  disease,  the  reader 
should  picture  to  himself  a  woman  desperately  ill,  in  the  typhoid  condition, 
of  a  light  yellow  colour,  and  with  many  subcutaneous  and  other  haemor- 
rhages. I  have  known  a  case  of  severe  pyaemia  mistaken  for  acute  yellow 
atrophy. 

The  onset  varies  :  the  patient  may  be  suddenly  seized  with  a  rigor,  and 
quickly  become  very  ill,  with  headache,  backache,  great  prostration, 
vomiting,  fever,  and  in  a  few  hours  jaundice ;  and,  to  show  how  sudden  the 
onset  may  be,  I  may  mention  that  I  have  known  a  case,  thought  to  be 
pneumonia,  with  jaundice,  turn  out  to  be  acute  yellow  atrophy.  But  she 
vol.  i. — 48 


754  ALIMENTARY  SYSTEM. 

may  not  seem  dangerously  ill,  or  even  be  jaundiced,  for  four  or  five  days  ; 
and  sometimes  the  disease  is  preceded  by  marked  symptoms  of  indigestion. 
The  jaundice  is  never  very  deep  ;  indeed,  Boix  says  it  may  be  absent.  Its 
depth  bears  no  relation  to  the  intensity  of  the  disease.  Bile  is  always 
present  in  the  stools.  There  is  usually  pain  and  tenderness  in  the  hepatic 
region,  and,  unless  emphysema  or  some  other  source  of  error  makes  it 
difficult  to  obtain  an  exact  idea  of  the  size  of  the  liver,  careful  percussion 
will  show  that  the  organ  day  by  day  diminishes  in  size,  until  the  hepatic 
dulness  is,  perhaps,  not  more  than  a  third  of  its  normal  width ;  but  it  must 
be  remembered  that  in  the  early  stages  of  the  disease  the  organ  may  be 
slightly  enlarged,  and  that  the  patient  may  die  before  the  atrophy  has 
proceeded  far.  The  spleen  is  slightly  enlarged,  and  may  be  tender; 
the  tongue  is  dry  and  brown;  there  is  often  much  blood  about 
the  mouth,  and  this  makes  the  breath  very  foul.  Vomiting  is 
often  troublesome,  and  the  vomit  may  be  black  from  altered  blood. 
Sometimes  there  is  constipation,  at  others  diarrhoea ;  the  motions  may 
contain  blood,  and  may  be  passed  into  the  bed.  The  pulse  is  rapid, 
unless  the  jaundice  is  so  deep  as  to  slow  it,  soft,  very  feeble,  and  often 
irregular ;  there  is  considerable  dyspnoea,  and  the  respirations  are  rapid, 
out  of  proportion  to  the  temperature  ;  indeed,  there  can  be  little  doubt  that 
some  toxic  product  is  present  in  the  blood,  which  is  a  powerful  cardiac  and 
respiratory  depressant.  The  nervous  symptoms  collectively  known  as  the 
typhoid  state,  are  very  striking.  The  patient  lies  prostrate  on  her  back,  in 
a  state  of  low,  muttering  delirium,  which  is  rarely  violent,  and  is  more 
marked  at  night.  Fine  fibrillary  tremors  may  be  seen  in  her  muscles,  she 
picks  at  the  bedclothes,  and  subsultus  may  be  noticed.  Although  dulled 
and  lethargic,  she  is,  till  towards  the  end,  continually  awake ;  but  then  coma 
gradually  supervenes.  She  becomes  immobile,  the  cornea  are  insensitive, 
a  sweat  breaks  out  on  her  face,  and  finally  death  ends  the  scene.  Convul- 
sions are  rare.  Bleeding  may  occur  almost  anywhere,  but  is  most  common 
under  the  skin,  from  the  nose,  or  from  the  uterus.  If  pregnant,  the  patient 
usually  miscarries.  The  temperature  is  very  variable ;  sometimes  it  is 
raised  a  few  degrees,  but  often  it  is  subnormal. 

The  patient  usually  passes  her  urine  under  her ;  it  is  scanty,  high 
coloured,  and  of  a  high  specific  gravity ;  it  contains  a  few  granules  and 
hyalin  casts,  usually  some  albumin,  and  perhaps  blood.  Very  little  bile 
pigment  may  be  present  in  it,  and  it  is  usually  impossible  to  detect  any 
bile  acids.  The  striking  thing  is  the  great  diminution  of  iirea,  and  the 
presence  of  stellate  sheaves  or  globular  masses  of  crystals  of  tyrosin,  and 
rounded  laminated  crystalline  masses  of  leucin.  These  are  generally  quite 
easy  to  detect  with  the  microscope,  especially  if  the  urine  is  centrifuged  ; 
they  become  more  abundant  as  the  disease  progresses,  and  are  diagnostic  of 
acute  yellow  atrophy.  The  salts  of  the  urine  are  diminished.  The  patient 
is  usually  dead  within  a  week  of  the  onset  of  the  severer  symptoms,  but  a 
few  cases  of  recovery  are  recorded. 

Diagnosis. — Acute  yellow  atrophy  is  almost  certainly  a  definite 
disease.  The  points  of  difference  from  yellow  fever,  malaria,  typhoid  fever, 
pneumonia,  pyaemia,  typhus,  scarlet  fever,  and  relapsing  fever  are  men- 
tioned under  these  headings.  In  all  these  conditions  the  liver  may  become 
very  fatty,  but  a  fatty  liver  does  not  resemble  that  affected  with  acute 
yellow  ;atrophy,  and  although  Murchison  states  that  crystals  of  leucin 
and  tyrosin  may  be  found  in  the  liver  and  kidneys  when  they  have  under- 
gone  fatty  degeneration,  this  is  certainly  quite  exceptional      Epidemic 


DISEASES  OF  THE  LIVER.  755 

jaundice  and  Weil's  disease  are  little  understood,  but  their  whole  course 
marks  them  off  from  acute  yellow  atrophy ;  and  the  same  is  true  of  the 
jaundice  induced  by  poisons,  such  as  snake  poison.  Other  poisons  which 
will  cause  jaundice  are  the  fungus  known  as  Helvetia  esculenla,  male  fern, 
toluylendiamine,  glycerin,  chloroform,  ether,  pyrogallic  acid,  and  naphthol. 
Phosphorus  is  a  sufficiently  common  poison  to  deserve  separate  mention. 
For  the  first  few  hours  after  taking  it  there  are  no  effects.  Then  abdominal 
pain,  nausea,  and  vomiting  set  in.  The  vomited  matter  often  smells  of 
phosphorus,  and  is  luminous  in  the  dark.  There  is  some  collapse,  but  these 
symptoms  usually  pass  off,  and  the  patient  soon  appears  much  better.  But 
in  three  or  four  days,  jaundice,  which  soon  becomes  deep,  is  noticed,  and 
the  liver  may  be  a  little  enlarged.  There  is  intense  prostration  and  great 
thirst,  the  skin  is  cold,  the  pulse  feeble  and  rapid.  Vomiting  of  blood  and 
bloody  diarrhoea  may  be  observed,  but  these  two  symptoms  are  not  severe. 
The  urine,  which  is  scanty,  high-coloured,  albuminous,  bile-stained,  and 
perhaps  bloody,  may  contain  crystals  of  leucin  and  tyrosin.  Muscular 
twitchings  are  noticed,  and  the  patient  dies  comatose.  At  the  post-mortem 
there  is  general  fatty  degeneration,  affecting  principally  the  liver,  which 
may  be  extremely  fatty,  but  it  never  looks  as  though  it  were  affected  with 
acute  yellow  atrophy.  Haemorrhages  in  most  of  the  organs  of  the  body  are 
common. 

The  drown  atrophy  of  Wilks  and  Moxon,  called  chronic  atrophy  by 
Frerichs,  and  red  atrophy  by  Eokitansky,  must  be  sharply  distinguished 
from  acute  yellow  atrophy,  to  which  it  bears  no  relation.  The  liver  is 
atrophied,  it  may  weigh  only  24  oz.,  it  is  flabby,  and  varies  from  dark  brown 
to  red.  The  cells  are  atrophied,  and  often  ruptured ;  the  ramifications  of 
the  extremities  of  the  portal  vein  are  destroyed,  so  that  the  minute 
branches  of  it  end  in  blind  extremities,  and  the  organ  cannot  be  injected 
from  it.  There  are  symptoms  during  life  of  obstructed  portal  circulation, 
but  the  condition  is  so  very  rare  that  we  know  very  little  about  it. 

Prognosis  and  treatment. — These  patients  rarely  recover.  The 
only  treatment  is  to  maintain  their  strength. 


ICTEEUS  NEONATOEUM. 

Newly-born  children  are  liable  to  many  forms  of  jaundice.  The 
commonest,  which  is  most  often  seen  in  foundling  hospitals,  appears  two 
or  three  days  after  birth,  and  disappears  within  two  or  three  weeks.  The 
child  does  not  appear  very  ill.  The  urine  may  contain  bile ;  the  faeces  are 
pale.     The  cause  of  this  variety  of  jaundice  is  not  known. 

There  is  also  a  very  rare  severe  form,  which  is  usually  fatal  in  a  few 
days,  and  is  often  accompanied  by  haemorrhage  from  the  umbilical  cord. 
The  jaundice  is  very  dark,  the  child  suffers  from  diarrhoea,  haemoglobinuria, 
pyrexia,  and  finally  coma,  and  perhaps  convulsions.  This  variety  is 
probably  due  to  septic  infection  through  the  umbilical  cord.  The  kidneys 
usually  show  acute  nephritis,  with  many  haemorrhages  in  their  substance. 

Jaundifte  in  the  new-born  may  also  be  due  to  congenital  obliteration  of 
the  common  duct,  to  syphilitic  disease  of  the  liver,  and  in  very  rare  instances 
to  a  calculus.  It  is  said  that  new-born  children  may  suffer  from  "  catarrhal 
jaundice." 


756  ALIMENTARY  SYSTEM. 

NERVOUS  JAUNDICE. 

Although  this  is  rare,  there  is  no  doubt  that  it  exists.  Many  instances 
in  which  some  severe  fright  or  emotion  caused  jaundice  occur  in  medical 
literature,  as,  for  example,  that  of  a  man  who  became  jaundiced  just  before 
he  was  about  to  fight  a  duel.  I  have  heard  of  the  case  of  a  child  who 
became  jaundiced  when  she  saw  her  sister  accidentally  drowned.  The 
cause  of  the  jaundice  in  these  cases  is  unknown.  It  passes  off,  and  no 
special  treatment  is  necessary. 

GALLSTONES. 

Etiology.  —  The  origin  of  gallstones  is  very  obscure.  Several 
observers,  working  under  the  direction  of  Naunyn  in  his  laboratory  at 
Strassburg,  have  shown  that  the  amount  of  cholesterin  in  the  bile  is  quite 
independent  of  the  quantity  of  this  substance  in  the  food,  nor  is  it 
influenced  by  any  alterations  in  diet,  by  any  particular  disease,  or  by 
the  quantity  in  the  blood.  Naunyn  points  out  that  the  secretion  from 
diseased  mucous  membranes  often  contains  considerable  quantities  of 
cholesterin,  and  as  this  substance  is  always  increased  in  the  bile  from  which 
calculi  are  deposited,  he  suggests  that  the  formation  of  gallstones  may  be 
partly  due  to  the  excess  of  cholesterin  which  follows  disease  of  the 
mucous  membrane  of  the  biliary  passages.  As  a  proof  of  the  importance 
of  the  secretion  of  cholesterin  from  the  biliary  mucous  membrane,  we  may 
mention  that  stones  may  be  found  in  diverticula,  or  pockets  of  the  biliary 
passages,  which  have  evidently  been  quite  shut  off  from  the  passages,  and 
therefore  from  the  bile,  for  some  time,  although  microscopic  examination 
shows  that  the  stone  was  continually  growing.  It  will  be  remembered  that 
the  other  chief  constituent  of  calculi,  besides  cholesterin,  is  bilirubin- calcium; 
and  therefore  it  is  important  to  bear  in  mind  that  the  quantity  of  calcium 
in  the  bile  is  quite  uninfluenced  by  the  diet,  but  that  the  mucus  secreted 
by  a  diseased  mucous  membrane  contains  lime.  It  seems  possible,  there- 
fore, that  the  reason  why  women  suffer  from  gallstones  so  much  more 
frequently  than  men,  is  that  the  habit  of  tight-lacing  damages  the  gall 
bladder,  the  mucous  membrane  of  which,  therefore,  secretes  considerable 
amounts  of  cholesterin  and  calcium.  But  these  facts  will  not  completely 
explain  the  formation  of  gallstones,  for  Happel  has  published  some 
tables  which  show  that  cholesterin  is  soluble  to  the  extent  of  5  per  cent, 
in  olein,  and  also  (although  to  a  considerably  less  extent)  in  soaps,  and 
glycocholate  and  taurocholate  of  sodium ;  and  that  all  those  substances  are 
present  in  human  bile  in  ample  quantity  to  keep  in  solution,  at  the  body 
temperature,  all  the  cholesterin  it  ever  contains  ;  and  although  the  decom- 
position of  the  glycocholic  and  taurocholic  acids  will  to  some  extent 
diminish  the  power  of  the  bile  to  hold  in  solution  the  cholesterin,  still  this 
diminution  is  not  great  enough  to  be  important ;  and  therefore  we  must 
conclude  that  the  formation  of  a  gallstone  cannot  depend  upon  mere 
excess  of  cholesterin ;  and,  further,  we  learn  that  crystals  of  it,  seen  in  the 
bile  at  a  post-mortem,  must  have  separated  out  after  death,  probably 
owing  to  the  cooling  of  the  body.  These  facts  suggest  that  cholesterin, 
before  it  can  form  a  gallstone,  must  be  precipitated  about  some  body 
acting  as  a  nucleus ;  although  epithelial  cells  can  be  seen  floating  in  bile, 
even  when    no   gallstones  are   present,   Naunyn   brings    forward   much 


DISEASES  OF  THE  LIVER.  757 

evidence  to  show  that,  when  these  cells  have  undergone  fatty  degenera- 
tion, they  can  themselves  form  cholesterin,  and  further  lead  to  the 
aggregation  around  them  of  amorphous  cholesterin  (which  later  becomes 
crystalline)  and  bilirubin -calcium  from  the  bile.  The  deposition  of 
bilirubin-calcium  is  favoured  in  another  way,  for  although  human  bile  also 
contains  an  abundance  of  lime  salts  and  bilirubin,  and  may  even  be 
artificially  concentrated  without  any  precipitation  of  bilirubin-calcium, 
certain  albuminous  substances  greatly  favour  the  precipitation  of  this 
substance,  and  it  may  well  be  that  epithelial  cells  or  an  albuminous 
secretion  from  the  mucous  membrane  of  the  biliary  passages  in  this  way 
help  the  precipitation  of  the  bilirubin-calcium  constituent  of  a  gallstone. 
A  biliary  calculus  is  first  a  soft  minute  mass,  which  may  be  moulded  by 
the  gall  bladder,  and  several  of  these  masses  may  stick  together.  Then,  if 
the  calculus  is  to  become  hard,  a  crust  of  the  chief  constituent  forms 
on  the  outside,  and  in  the  inner  side  of  this  the  harder  part  of  the 
soft  contents  are  deposited,  leaving,  if  there  is  sufficient  soft  material,  a 
little  collection  of  the  fluid  in  the  centre.  In  this  way  it  is  easy  to  under- 
stand how  some  stones  may  be  solid  throughout,  others  may  be  hollow, 
some  may  be  soft,  others  hard.  The  further  growth  of  the  stone  takes 
place  by  deposition  from  without,  if  the  bile  can  reach  it,  of  both  bilirubin- 
calcium  and  cholesterin ;  but  if  the  cystic  duct  is  blocked,  only  cholesterin, 
secreted  from  the  mucous  membrane,  will  be  precipitated.  The  lamina- 
tion of  the  deposits  probably  depends  upon  the  fact  that,  owing  to 
temporary  blocking  of  the  cystic  duct,  sometimes  no  bile  reaches  the  stone. 
It  is  of  interest,  in  connection  with  this  subject,  to  note  that  the  intro- 
duction of  foreign  bodies  into  the  gall  bladder  does  not  lead  to  the 
precipitation  of  cholesterin  or  bilirubin-calcium  around  them  to  form  a 
gallstone ;  indeed,  gallstones  introduced  into  a  dog's  gall  bladder  undergo 
slow  solution  there. 

The  frequency  of  gallstones  bears  upon  their  etiology.  The  most 
recent  investigations  on  this  point  are  those  of  Schroder,  who  examined  all 
the  patients  dying  in  the  Strassburg  Hospital,  which  contains  both  a 
children's  department  and  an  infirmary.  He  found  that  12  per  cent,  of  all 
the  bodies  examined  contained  gallstones,  distributed  as  follows  among  the 
different  decades: — Under  20  years,  2-4  per  cent.;  between  20  and  30  years, 
3-2  per  cent. ;  between  30  and  40  years,  1T5  per  cent. ;  between  40  and  50 
years,  11*1  per  cent.;  between  50  and  60  years,  9*9  per  cent. ;  over  60  years, 
25-2  per  cent.  4*4  per  cent,  of  the  male  and  20-6  per  cent,  of  the  female  bodies 
examined  contained  gallstones,  and  they  were  much  more  frequent  in 
those  women  who  had  borne  children  than  in  those  who  had  not.  These 
figures  suggest  that  both  pregnancy  and  tight-lacing  favour  the  for- 
mation of  gallstones,  which  are  indeed  especially  often  seen  in  women 
on  whose  livers  the  groove  which  shows  tight-lacing  is  evident.  Both 
prevent  the  free  flow  of  bile,  because  they  hamper  the  movements  of  the 
diaphragm,  which  greatly  aid  the  biliary  flow ;  and  a  floating  right  kidney, 
which  is  so  much  commoner  in  women  than  men,  may  by  its  compression 
of  the  bile  ducts  also  hamper  the  flow.  Mitral  disease,  as  shown  by  Brock- 
bank,  is  a  cause.  Lastly,  the  sedentary  life  led  by  women  predisposes  to 
stagnation  of  the  bile.  This  last  cause  is  especially  operative  in  old  age, 
in  which,  too,  as  Charcot  has  shown,  the  plain  muscle  of  the  biliary 
passage  undergoes  atrophy;  and,  further,  it  is  only  probable  that  the 
epithelium  of  the  gall  bladder  will  be  more  likely  to  be  diseased  in  the 
old  than  in  the  young.     Neither  diet,  locality,  occupation,  social  position, 


758  ALIMENTARY  SYSTEM. 

hereditary  influence,  or  gout  have  any  special  influence  on  the  formation  of 
gallstones. 

Healthy  bile  is  sterile,  but  Naunyn  considers  that  stagnation  of  it 
favours  the  growth  in  it  of  the  Bacillus  coli  communis.  This  micro- 
organism may,  he  suggests,  lead  to  the  diseases  of  the  mucous  membrane  of 
the  gall  bladder,  which  induces  the  formation  of  the  stone.  This  is  a  more 
probable  supposition  than  that  the  stagnation  of  the  bile  causes  the  inflam- 
mation of  the  mucous  membrane  (cholangitis),  for  the  cause  of  the  stag- 
nation is  usually  more  or  less  permanent,  while  the  invasion  by  the 
bacterium  might  be  transitory;  and  when  many  gallstones  are  present, 
not  only  are  they  of  the  same  composition,  but  they  appear  to  be  of  the 
same  age.  It  is,  however,  by  no  means  proved  that  the  B.  coli  is  the  sole 
cause  of  gallstones,  for  Gilbert,  examining  the  bile  in  thirty-six  cases,  of 
gallstones  in  which  an  operation  was  performed,  found  living  B.  coli  in 
twelve  and  dead  B.  coli  in  two ;  but  it  must  be  remembered  bacilli  might 
start  the  formation  of  a  gallstone  and  subsequently  die. 

The  influence  of  carcinoma  is  uncertain.  It  is  common  to  find  gall- 
stones present  when  the  gall  bladder  is  carcinomatous,  and  it  may  be  that 
some  mass  of  carcinoma,  by  pressure  on  the  duct,  has  led  to  stagnation 
of  the  bile,  and  that  then  the  B.  coli  communis,  setting  up  some 
cholangitis,  has  led  to  a  gallstone ;  but,  on  the  other  hand,  many  authors 
consider  that  the  gallstones  are  in  these  cases  the  cause  of  the  carcinoma. 
The  minute  bihrubin-calcium  calculi  found  in  the  substance  of  the  liver 
are  more  common  when  that  organ  is  diseased  than  when  it  is  healthy. 

From  the  facts  just  given,  it  will  be  seen  that  it  is  supposed  that,  in 
some  cases  at  least,  the  B.  coli  communis  sets  up  cholangitis ;  this  leads  to 
shedding  of  the  epithelium,  which  forms  a  nucleus  for  the  stone,  and  to  an 
increased  formation  of  cholesterin  and  bilirubin-calcium,  which  are  precipit- 
ated on  the  nucleus,  and  the  whole  process  is  aided  by  a  retardation  of  the 
flow  of  bile.  It  has  been  suggested  that  other  micro-organisms,  especially 
the  typhoid  bacillus,  may  cause  gallstones,  but  the  evidence  is  very 
slender.  Sufferers  from  gallstones  do  not  give  a  history  of  typhoid  fever 
oftener  than  other  people. 

Morbid  anatomy. — Biliary  calculi,  or  gallstones,  may  be  found 
either  in  the  gall  bladder,  the  cystic  duct,  the  common  duct,  the  hepatic 
duct,  or  the  liver  itself.  They  are  far  more  commonly  formed  in  the  gall 
bladder  than  elsewhere,  and  from  these  are  often  forced  into  either  the 
cystic  or  the  common  duct. 

Cholesterin  and  bilirubin-calcium  are  the  most  important  constituents 
of  gallstones;  calcium-carbonate,  although  frequently  present,  is  usually 
found  only  in  small  quantities.  Occasionally  biliverdin,  bilicyanin,  bili- 
fuscin,  and  bilihaemin  are  met  with,  and  they  too  are  nearly  always 
combined  with  calcium.  Minute  traces  of  copper  and  iron  are  often 
mixed  with  the  bilirubin-calcium.  In  quite  exceptional  instances  metallic 
mercury,  calcium  sulphate,  and  calcium  phosphate  have  been  found,  and 
traces  of  free  bilirubin  and  the  salts  of  the  bile  acids  may  soak  into  the 
stones  from  the  bile. 

Gallstones  are  most  frequent  in  the  gall  bladder,  and  they  are  usually 
about  the  size  of  a  pea,  seldom  larger  than  a  cherry,  and  often  quite  small, 
it  may  be  so  minute  that  a  number  of  them  form  a  sort  of  sand.  "When 
very  small  they  are  rounded,  but  when  larger  they  are  usually  faceted, 
because  at  first  they  are  soft,  and  as  commonly  more  than  one  is  present, 
contiguous  gallstones  become  pressed  against  each  other.    If  they  are  still 


DISEASES  OF  THE  LIVER.  759 

soft  when  the  patient  dies,  they  may  be  crushed  in  the  hand,  but  most 
often  the  central  part  only  is  soft,  and  is  surrounded  by  a  hard  shell  of 
varying  thickness.  Their  colour  is  usually  brown,  yellow,  or  white,  or 
some  mixture  of  these  colours.  On  section  of  the  stone,  it  will  be  seen  that 
some  parts  are  darker  than  others,  they  feel  soapy,  the  cholesterin  in  them 
may  glitter,  and  there  may  be  a  central  cavity  containing  a  yellowish, 
alkaline  liquid.  Any  number,  from  one  to  many  thousands,  may  be  seen  in 
one  gall  bladder,  but  in  the  same  patient  all  the  gallstones  always  have 
the  same  constitution  and  appearance. 

In  comparatively  rare  cases  the  gallstone  may  be  larger  than  a  cherry, 
and  sometimes  they  may  be  as  big  as  a  hen's  egg.  These  large  stones  are 
usually  solitary,  and  therefore  rarely  faceted.  They  almost  always  lie  in 
contact  with  the  wall  of  the  gall  bladder,  and  may  even  entirely  fill  it.  In 
the  exceptional  instances,  in  which  more  than  one  large  stone  is  present,  a 
distinct  crepitus  may  sometimes  be  felt  during  life,  if  the  hand  is  placed 
firmly  over  the  gall  bladder.  Occasionally  stones  grow  to  a  larger  size  in 
the  cystic  or  in  the  common  duct ;  and  wherever  it  is,  a  stone  may  form  a 
sacculus  for  itself. 

Sometimes  one  constituent  of  a  gallstone  preponderates  to  such  an 
extent,  that  the  stone  differs  in  appearance  from  the  common  stone,  which 
is  composed  of  cholesterin  and  bilirubin  calcium,  and  has  just  been  described. 
Naunyn  draws  up  the  following  list  of  these  rarer  stones : — (a)  Pure 
cholesterin  stones.  These  are  hard,  rounded,  non-faceted,  large,  and  nearly 
always  white,  translucent,  and  smooth.  They  contain  hardly  anything  but 
cholesterin.  On  section,  they  are  white  and  crystalline  throughout,  with- 
out any  signs  of  stratification,  (b)  Laminated  cholesterin  stones.  In  form 
and  size  these  resemble  those  of  pure  cholesterin.  They  may  be  almost  any 
colour,  rarely  they  are  soft  and  faceted.  When  cut  they  show  a  more  or 
less  crystalline  structure,  with  alternately  white  and  dark  laminae.  They 
consist  for  the  most  part  of  pure  cholesterin,  and  may  contain  90  per  cent, 
of  it.  (c)  Mixed  bilirubin-calcium  calculi.  These  too  contain  cholesterin, 
but  in  much  smaller  quantity,  although  it  may  occasionally  form  25  per 
cent,  of  the  stone.  They  are  mostly  large,  and  may  be  faceted.  The 
nucleus  consists  of  cholesterin ;  outside  this  are  broad  laminae,  very  liable  to 
flake  off,  and  consisting  chiefly  of  bilirubin-calcium  with  some  cholesterin. 
(d)  Pure  bilirubin-calcium  calculi.  These  contain  the  merest  trace  of 
cholesterin,  but  a  large  amount  of  bilirubin-calcium  with  varying  quantities 
of  the  calcium  compounds  of  other  biliary  pigments,  especially  bilihaemin. 
These  stones  vary  in  size  from  a  grain  of  sand  to  a  pea,  and  are  usually 
rough  and  irregular.  They  are  grey  or  blackish  brown,  and  often  as  soft  as 
wax,  although  they  may  be  hard  and  brittle  ;  their  shape  is  most  irregular, 
and  they  may  have  processes  on  them,  (e)  Amorphous,  or  incompletely 
crystalline  cholesterin  calculi.  These  are  quite  small,  and  look  like  pearls. 
(/)  Calcium  carbonate  occasionally  forms  the  chief  ingredient  of  gallstones. 
(g)  Compound  calculi.  Sometimes  it  is  quite  evident,  on  cutting  into  a 
calculus,  that  a  small  calculus  of  one  variety  has  formed  the  nucleus  for 
one  of  another  variety,  (h)  In  cattle,  casts — either  solid  or  tubular — of 
the  bile  ducts  may  occur.  They  always  consist  of  pure  bilirubin-calcium. 
Casts  are  very  rare  in  man.     (e)  (/)  (g)  (h)  are  all  extremely  rare. 

Symptoms. — In  considering  these,  we  must  bear  in  mind  that,  in  the 
first  place,  gallstones  are  often  found  in  the  bodies  of  those  who  during  life 
showed  no  symptoms  of  them ;  and,  secondly,  that  there  is  no  satisfactory 
evidence  that  they  ever  become  dissolved. 


760  ALIMENTARY  SYSTEM. 

It  appears  that  gastro-intestinal  contractions  may  set  up  contractions  of 
the  gall  bladder  or  ducts,  and  so  lead  to  an  attack  of  biliary  colic,  for  this 
often  appears  to  be  induced  by  irritating  articles  of  diet.  It  is  obvious  that 
the  severity  of  the  colic  will  depend  upon  the  force  of  the  contractions 
behind  the  stone,  the  expansibility  of  the  ducts,  the  shape  and  consistency 
of  the  calculus,  and  the  pressure  of  bile  behind  it.  This  last  is  probably 
unimportant,  for  the  bile  is  secreted  at  such  a  very  low  pressure.  The 
narrowest  part  traversed  by  a  stone  is  the  cystic  duct  and  the  opening  of 
the  common  duct  into  the  duodenum ;  stones  are  therefore  most  frequently 
impacted  in  these  situations. 

Attacks  of  gallstone  colic  come  on  rather  more  frequently  at  night 
than  in  the  day,  and  are  sometimes  preceded  by  slight  premonitory 
symptoms,  resembling  those  of  the  fully-developed  attack,  and  these  are 
very  likely  due  to  the  passage  of  biliary  gravel.  The  great  and  leading 
feature  of  an  attack  is  agonising  pain  in  the  right  hypochondrium,  which 
usually  comes  on  suddenly.  Women  often  say  that  labour  pains  are 
not  so  severe  as  those  of  gallstone  colic.  The  patient  writhes  in  agony, 
and  generally  applies  to  the  pain  the  same  terms — stabbing,  cutting,  and 
boring — as  are  used  by  sufferers  from  intestinal  colic.  It  commonly 
radiates  through  to  the  back  and  often  to  any  part  of  the  abdomen ;  and 
in  extreme  cases  into  the  upper  part  of  the  thorax,  the  head,  the  arms,  or 
even  the  right  thigh.  It  is  not  so  frequent  in  the  right  shoulder  as  other 
diseases  of  the  liver  would  lead  us  to  expect.  Usually  it  lasts  a  few  hours, 
but  it  may  endure  for  days  ;  occasionally  it  ends  quite  suddenly,  but  more 
commonly,  although  it  suddenly  becomes  much  less  considerable,  pain  and 
discomfort  last  for  some  time.  It  must  not  be  imagined  that  all  attacks 
are  as  severe  as  this  :  there  are  all  grades,  from  that  just  described  to  a 
mere  sense  of  discomfort  in  the  region  of  the  gall  bladder ;  and  there  is, 
I  think,  no  doubt  that  many  pains  in  women  set  down  to  indigestion  are 
really  clue  to  biliary  colic. 

Vomiting  is  almost  as  common  as  pain.  It  is  usually  severe  and 
frequently  repeated,  and  the  patient  continues  to  retch  after  the  stomach  is 
quite  empty.  The  pressure  of  the  abdominal  muscles  which  empty  the 
stomach,  helps  no  doubt  the  passage  of  the  gallstone,  and  is  also  the  cause 
of  such  a  thorough  emptying  of  the  ducts,  that  bile  regurgitates  through  the 
pylorus,  and  consequently  the  vomit  is  usually  green.  Even  gallstones 
may  pass  into  the  stomach,  and  be  found  in  the  vomit.  If  the  stone  is 
irregular,  some  bile  is  probably  pressed  past  it. 

Jaundice  is  the  next  most  common  symptom,  occurring  in  a  half  to 
three-quarters  of  all  the  cases.  It  is  first  noticed  after  the  onset  of  the 
pain,  and  is  in  a  few  hours  quite  deep.  After  the  pain  has  ceased,  the  bile 
rapidly  disappears  from  the  urine ;  but  the  staining  of  the  skin  and  con- 
junctiva will,  if  it  has  been  at  all  deep,  remain  many  days.  The  stools  are 
often  of  a  light  colour,  but  the  obstruction  to  the  flow  of  bile  must  be  com- 
plete and  last  some  time  for  these  to  be  quite  clay-coloured.  As  might  be 
expected,  any  of  the  symptoms  due  to  retention  of  bile  from  any  cause  may 
be  present.  They  will  be  found  described  under  the  heading  of  "  Jaundice  " ; 
of  them  a  feeling  of  intense  depression,  a  slow  pulse,  and  constipation,  are 
the  most  common.  The  abdominal  muscles  in  the  neighbourhood  of  the 
gall  bladder  are  often  rigidly  contracted,  and  this  may  be  a  valuable  aid  to 
the  diagnosis  when  the  other  symptoms  are  obscure.  Occasionally  the 
patient  complains  of  painful  cramps  in  various  parts  of  the  body. 

The  edge  of  the  liver  is  very  commonly  painful ;  and  even  when  the 


DISEASES  OF  THE  LIVER.  761 

organ  is  not  enlarged,  if  the  hand  be  placed  under  the  ribs,  severe  pain  is 
felt  on  deep  inspiration,  but  often  the  swollen  organ  is  easy  to  feel  below 
the  ribs,  and  if  the  attack  lasts  some  time  its  edge  may  extend  to  a  point 
midway  between  the  costal  margin  and  the  umbilicus.  In  many  cases  the 
gall  bladder  is  enlarged,  and  then  it  is  often  tender.  It  is  felt  as  a  rounded 
swelling  at  the  outer  margin  of  the  right  rectus,  just  under  the  ribs.  It 
may  enlarge  even  when  bile  cannot  reach  it,  owing  to  complete  obstruction 
of  its  own  duct ;  then  the  distension  is  due  to  the  secretion  of  colourless 
mucus. 

The  irritation  of  the  gallstone  occasionally  causes  the  temperature  to 
rise,  it  may  be  to  104°,  or  even  more.  It  mounts  very  quickly,  and  does  not 
remain  up  long.  The  height  does  not  bear  any  necessary  relation  to  the  pain, 
and  often  the  pyrexia  is  accompanied  by  a  rigor.  This  shivering  and 
pyrexia  must  be  carefully  distinguished  from  that  due  to  suppuration  in 
the  liver  or  bile  passages,  or  to  ulceration  of  the  biliary  passages ;  then  the 
rises  of  temperature  are  frequently  repeated.1 

Occasionally  a  little  albumin  is  found  in  the  urine.  If  the  attack  is 
very  severe,  or  the  patient  very  old,  there  may  be  much  collapse — even 
fatal — with  a  feeble  pulse  and  considerable  sweating.  If  this  or  the 
vomiting  are  excessive,  the  patient  may  be  very  thirsty,  and  commonly  she 
completely  loses  her  appetite. 

The  motions  passed  after  an  attack  should  always  be  searched  for 
stones,  and  the  quest  should  not  be  given  up  for  at  least  a  fortnight.  The 
motion  should  be  thrown  upon  a  hair  sieve,  and  then  slowly  washed  with 
water.  Often  no  stone  is  found,  and  then  it  has  usually  become  dissolved 
in  the  intestine ;  this  nearly  always  happens  to  bilirubin-calcium  calculi ; 
in  fact  it  is  almost  invariable  that  a  stone  passed  per  rectum  is  very  hard, 
and  consists  chiefly  of  cholesterin.  In  exceptional  cases  the  stone  remains 
embedded  in  the  duct,  which,  however,  dilates  enough  to  let  some  bile  past, 
or  still  more  rarely  it  may  slip  back  into  the  gall  bladder.  Sometimes  a 
great  many — it  may  be  over  200 — are  found  in  the  same  motion,  or  in  a 
few  motions  passed  closely  upon  each  other.  Should  a  very  large  stone 
be  found  in  the  intestine,  it  is  clear  that  it  can  only  have  got  there  from 
ulceration  into  the  gut.  Probably  no  stone  much  larger  than  a  cherry 
can  pass  by  the  natural  passages.  In  concluding  this  account  of  the 
symptoms,  I  would  again  remind  the  reader  that  the  attacks  vary  in 
severity,  from  a  slight  pain  to  a  continual  series  of  attacks  spread  over 
weeks ;  that  even  sometimes  the  pain  may  be  absent ;  that  when  a  patient 
has  had  one  attack  she  nearly  always  has  others ;  that  repeated  attacks  of 
jaundice  are  almost  diagnostic  of  gallstones,  and  that  the  prognosis  is 
almost  invariably  good ;  and,  lastly,  that  however  severe  the  contractions, 
rupture  of  the  gall  bladder  from  this  cause  is  one  of  the  rarest  events 
known. 

Complications. — The  presence  of  a  gallstone  may  lead  to  many  com- 
plications, which  will  be  described  under  the  following  seven  principal 
heads,  less  important  complications  being  mentioned  incidentally.  For 
any  of  them  it  is  almost  necessary  that  the  stone  should  be  impacted,  and 
therefore  it  follows  that  they  are  all  usually  secondary  to  the  presence  of 
large  stones  either  in  the  cystic  duct  or  at  the  duodenal  end  of  the  common 
duct :  and  it  must  be  remembered  that  the  stone  can  probably  increase  in 
size  after  it  has  become  impacted. 

1  It  will  be  noticed  that  these  symptoms  are  of  very  short  duration  compared  to  the  pro- 
longed similar  symptoms  described  as  infective  cholangitis  on  p.  765. 


762  ALIMENTARY  SYSTEM. 

Simple  impaction. — ±11  extremely  rare  cases,  which  almost  always 
give  a  history  of  repeated  attacks  of  biliary  colic,  in  each  of  which  the 
jaundice  is  more  severe  than  in  former  attacks,  although  the  pain  commonly 
gets  less  and  less,  till  at  last  there  may  be  none,  a  stone  may  remain  im- 
pacted for  some  time  without  producing  any  of  the  evil  effects  just 
mentioned ;  and  if  it  is  fixed  in  the  cystic  duct,  not  even  jaundice  results ; 
and  if  it  is  tight  in  the  hepatic  or  common  ducts,  enough  bile  may  very 
exceptionally  pass  it  for  the  patient  not  to  be  jaundiced.  The  rule  is, 
however,  for  a  stone  impacted  in  the  common  or  hepatic  ducts  to  produce 
long-lasting  jaundice ;  and  often,  too,  this  follows  when  it  is  fixed  in  the 
cystic  duct ;  the  distension  of  this  or  the  over-full  gall  bladder  in  these 
cases  probably  presses  on  the  common  duct.  When  the  complete  obstruc- 
tion to  the  flow  of  bile  has  been  in  the  common  duct,  this,  the  hepatic 
ducts,  and  those  in  the  liver,  are  enormously  dilated,  and  may  contain  a 
pint  or  two  of  fluid,  and  a  distended  duct  has  been  mistaken  for  a  distended 
^all  bladder.  If  the  cystic  duct  is  completely  obstructed,  the  gall  bladder 
may  be  distended  by  its  own  colourless  secretion,  but  more  often  it  is 
empty  and  contracted.  Even  when  a  gallstone  has  been  impacted  for 
months,  the  symptoms  may  suddenly  cease,  because  the  stone  has  ulcerated 
into  the  intestine.  It  usually  passes  into  the  duodenum,  the  stone  having 
been  impacted  in  that  part  of  the  common  duct  which  lies  in  the  duodenal 
wall.  If  jaundice  has  been  present,  it  then  disappears ;  and  the  patient 
may  get  quite  well,  although  she  is,  if  the  stone  is  very  large,  always  liable 
to  intestinal  obstruction.  Occasionally,  the  fistulous  communication  with 
the  intestine  allows  bile,  but  not  the  gallstone,  to  pass  into  the  gut.  Death 
from  cholaemia,  due  solely  to  the  protracted  jaundice  caused  by  a  calculus, 
is  almost  unknown.  If  the  patient  dies,  it  will  be  found  that  the  calculus 
has  set  up  carcinoma  of  the  duct,  or,  in  quite  exceptional  cases,  ulceration 
and  cicatricial  constriction  of  it.  It  is  of  the  greatest  diagnostic  importance 
to  remember  that  protracted  jaundice,  due  solely  to  a  gallstone,  rarely  lasts 
more  than  three  months.  Deep  jaundice  of  longer  duration  than  this  is 
almost  invariably  due  to  growth,  and  indeed  jaundice  of  only  three  months 
is  much  more  often  due  to  this  than  to  gallstones.  The  chief  diagnostic 
points  are  the  previous  history,  the  other  symptoms  of  growth,  especially 
the  irregular  enlargement  of  the  liver,  and  the  fact  that  the  obstruction  to 
the  flow  of  bile  from  a  growth  is  more  complete  than  from  a  stone,  conse- 
quently fluctuations  in  the  depth  of  the  jaundice  and  in  the  colour  of  the 
usually  pale  stools  are  points  in  favour  of  gallstones,  although  slight 
fluctuations  may  be  met  with  in  growth. 

Dilatation. — A  distended  gall  bladder  forms  a  pear-shaped  and  often 
painful  tumour,  usually  situated  just  at  the  outer  border  of  the  right 
rectus,  but  sometimes  nearer  the  nipple  line,  and  sometimes  more  towards 
the  middle  line.  It  may  reach  to  the  umbilicus  or  even  beyond  it. 
It  feels  like  a  fluid  tumour,  it  can  be  shifted  laterally  with  the  hand, 
and  moves  freely  with  respiration.  The  respiratory  excursion  of  floating 
kidneys  and  omental  tumours  is  usually  much  less,  and  can  be  pre- 
vented by  putting  the  hand  firmly  on  their  upper  part ;  but  that  of  a 
gall  bladder  cannot,  nor  can  this  be  felt  bimanually  as  can  a  floating 
kidney.  Distension  of  the  stomach  with  gas  renders  a  floating  kidney  very 
difficult  to  feel,  but  it  simply  pushes  a  distended  gall  bladder  more  to  the 
right.  The  distended  bladder  is  usually  dull  on  percussion,  but  it  must 
not  be  forgotten  that  if  very  distended  it  may  become  bent  on  itself,  and 
then  it  sinks  back  into  the  abdomen,  so  that  resonant  colon  or  intestine 


DISEASES  OF  THE  LIVER.  763 

may  come  in  front  of  it.  Usually  the  diagnosis  is  so  easy  that  an  explor- 
atory puncture  is  not  needed,  but  if  this  method  is  adopted,  a  very  fine  short 
sterilised  needle  must  be  used,  and  the  tumour  should  be  punctured  where 
dull  and  prominent.  The  fluid  obtained  has  been  secreted  from  the  mucous 
membrane  of  the  gall  bladder,  and  it  is  commonly  free  from  bile,  for  this 
soon  gets  reabsorbed  after  the  obstruction  is  complete  ;  it  is  usually  clear, 
contains  little  or  no  albumin,  but  mucin  and  pavement  epithelium ;  but 
if  it  is  inflammatory,  of  course  albumin  and  pus  corpuscles  are  present. 

After  a  gall  bladder  has  been  dilated  some  time,  ridges  of  hypertrophied 
muscle  may  be  seen  when  it  is  opened,  and  later  on  the  mucous  membrane 
atrophies,  and  may  ulcerate  where  stones  are  in  contact  with  it.  These 
ulcers  may  heal  and  cicatrise.  In  most  cases  the  wall  of  the  gall  bladder 
is  finally  much  thickened.  In  some  very  rare  cases  it  may  be  calcified,  in 
others  septa  form  which  may  encapsule  the  calculi;  and,  lastly,  the  inner 
surface  of  the  gall  bladder  may  become  gangrenous.  Distension  of  the 
gall  bladder  is  almost  always  due  to  impaction  of  a  calculus  in  the 
cystic  duct,  but  exceptionally  it  may  be  caused  by  growth  of  the  cystic 
or  common  ducts,  some  pressure  from  without ;  or,  still  more  rarely,  the 
gall  bladder  undergoes  a  paralytic  distension,  of  which  I  have  seen  an 
instance  occurring  in  the  course  of  typhoid  fever. 

Nearly  always  the  course  of  events  is  that,  secondary  to  obstruction  of 
the  duct,  an  infective  slight  inflammation  of  the  lining  membrane  of  the 
gall  bladder  is  set  up  by  the  Bacterium  coli  commune,  for  this  micro-organism 
has  been  discovered  in  the  fluid  from  distended  gall  bladders,  which  con- 
tained but  little  albumin  and  only  a  few  leucocytes,  and  which  the  older 
observers  would  certainly  not  have  called  inflammatory,  especially  as  often 
there  were  no  general  signs,  such  as  rigors,  temperature,  etc.  But  this  is 
not  surprising  when  we  remember  that  the  virulence  of  this  particular 
micro-organism  is  very  variable  ;  but  severe  pyrexia,  rigors,  and  sweating 
may  develop,  and  the  number  of  leucocytes  and  the  quantity  of  albumin 
in  the  fluid  may  increase,  until  genuine  pus  is  formed,  and  we  have  an 
empyema  of  the  gall  bladder,  in  which  case  it  is  quite  possible  there  may 
be  a  secondary  infection,  with  streptococci  and  staphylococci.  But  the 
formation  of  pus  is  certainly  rare ;  the  usual  course  is  for  the  fluid  to 
contain  only  a  few  leucocytes  and  a  little  albumin,  and  for  the  general 
symptoms  to  be  only  moderately  severe.  As  the  cystic  duct  is  commonly 
blocked,  the  fluid  cannot,  by  means  of  the  bile  ducts,  infect  the  liver,  and 
consequently  there  are  not  usually  abscesses  there. 

In  some  few  cases,  however,  the  fluid  is  absolutely  sterile,  and  contains 
no  leucocytes  or  albumin,  and  the  secretion  of  mucus  in  the  gall  bladder 
may,  in  these  cases,  be  compared  to  the  collection  of  fluid  in  a  hydrocele. 
If  it  is  sterile,  or  if  it  contains  only  a  little  albumin  and  a  few  leucocytes, 
it  may  be  completely  absorbed,  even  when  the  obstruction  persists ;  but  if 
the  inflammation  is  more  severe,  it  may,  by  spreading  through  the  walls 
of  the  gall  bladder,  set  up  acute  peritonitis  ;  or  this  structure  may,  when 
its  walls  are  softened,  rupture  into  the  peritoneal  cavity,  or  externally 
into  some  neighbouring  viscus,  when  a  fistula  is  formed.  Gallstones  may 
be  discharged  through  such  fistula?. 

Abscess  of  the  liver. — This  is  a  rare  result  of  a  gallstone;  neverthe- 
less the  following  several  varieties  exist.  The  B.  coli  communis  is  always 
present,  and  very  often  streptococci  as  well. 

An  empyema  of  the  gall  bladder  may  invade  the  liver.  An  abscess 
around  an  impacted  stone  may  form  in  the  liver  substance.      A  stone 


764  ALIMENTARY  SYSTEM. 

may  ulcerate  through  the  wall  of  the  duct  in  which  it  lies,  into  the  liver, 
and  form  an  abscess  there.  Suppuration  may  take  place  around  one  or 
more  small  calculi  in  the  same  branch,  or  in  different  branches  of  the 
hepatic  duct ;  many  of  the  smaller  branches  of  the  duct  may  thus  become 
infected,  so  that  at  last  the  ducts  are  tubes  of  pus,  and  many  minute 
abscesses  may  be  present.  According  to  some  authorities,  bile,  dammed 
back  in  the  smaller  ducts,  leads  to  necrosis  of  the  liver  cells,  and  suppura- 
tion takes  place  around  these  minute  foci  of  dead  cells.  In  very  rare 
cases  a  stone  in  the  common,  cystic,  or  hepatic  ducts  may  set  up  some 
local  formation  of  pus,  and  the  process  may  spread  back  along  the  ducts 
until  the  liver  is  riddled  with  tubes  of  pus  and  small  abscesses  connected 
with  them.  The  most  common  form  of  hepatic  abscess  in  association  with 
gallstones  is  the  following.  An  empyema  of  the  gall  bladder,  or  an 
abscess  around  a  calculus,  may  directly  infect  a  branch  of  the  portal  vein, 
and  as  a  result,  numerous  small  abscesses  are  found  in  the  liver,  just  as 
in  any  other  case  of  portal  pysemia.  Inasmuch  as  the  cystic  vein  is 
returned  into  the  portal,  metastatic  venous  abscesses  in  the  liver  may 
result  from  inflammation  of  the  gall  bladder  and  large  bile  ducts. 

The  recognition  of  abscess  of  the  liver  due  to  gallstone  is  often  very 
difficult,  for,  as  has  already  been  pointed  out,  gallstones  may,  quite  apart 
from  any  suppuration,  cause  rigors,  pyrexia,  and  sweating,  and  a  swollen, 
tender  liver.  Our  guides  must  be  that,  if  an  abscess  be  present  in  the  liver, 
the  symptoms  are  more  severe ;  the  tenderness  of  the  liver  is  more  local, 
especially  during  the  rigor,  and  if  one  abscess  be  large  enough,  there  may 
be  local  signs,  as  swelling,  extreme  tenderness,  etc. ;  but  this  often  is  not 
the  case.  If  the  severe  signs  persist  some  time,  and  the  patient  is  dying, 
this  is,  of  course,  almost  conclusive  of  hepatic  suppuration ;  and  signs  of 
general  infection,  such  as  pulmonary  abscesses,  or  malignant  endocarditis, 
are  absolutely  conclusive.  It  may  be  quite  impossible  to  distinguish 
between  a  suppurating  growth  and  a  hepatic  abscess. 

Pistulae. — Gallstones  may,  either  by  ulceration  or  by  rupture  of  an 
abscess  around  them,  form  fistuke.  The  most  common  is  a  fistula  into  the 
duodenum,  and  this  may  be  due  either  to  a  fistula  between  the  gall  bladder 
and  this  part  of  the  intestine,  or  it  may  follow  the  impaction  of  a  stone 
at  the  lower  end  of  the  common  duct.  The  next  most  frequent  is  between 
the  gall  bladder  and  colon.  A  fistula  through  the  anterior  abdominal  wall  is 
rarer ;  it  is  usually  at  or  near  the  umbilicus,  and  very  rarely  a  fistula  may 
form  between  the  gall  bladder  and  the  stomach,  the  thorax,  the  jejunum,  the 
ileum,  the  portal  vein,  or  the  urinary  passages  ;  and,  lastly,  a  fistula  may  run 
into  the  retroperitoneal  tissue,  or  lead  to  a  communication  between  con- 
tiguous bile  ducts.  If  the  cystic  duct  is  patent,  and  the  gall  bladder  com- 
municates with  some  viscus  or  the  outer  surface  of  the  body,  much  bile 
may  escape  from  the  fistula ;  but  often,  with  external  fistuke,  the  flow  of 
bile  is  interfered  with,  as  the  passage  is  commonly  tortuous ;  and  therefore 
sometimes  the  patient  is  jaundiced,  and  she  may  die  from  choleemia  ;  but, 
apart  from  this,  the  presence  of  a  permanent  biliary  fistula  usually  exhausts 
her  so  much  that  death  results  after  a  time.  By  far  the  least  dangerous 
track  is  that  which  forms  when  a  stone  ulcerates  from  the  duodenal  end 
of  the  common  duct  into  the  duodenum.  Often,  when  this  has  happened, 
the  parts  look  so  natural  that  care  is  necessary  to  demonstrate  that  ulcera- 
tion has  taken  place.  I  once  made  a  post-mortem  examination  on  a  case 
in  which  a  fistulous  communication  existed  between  the  gall  bladder  and 
pylorus.     The  surrounding  inflammatory  thickening  led  to  constriction  of 


DISEASES  OF  THE  LIVER.  765 

the  pylorus,  and  the  patient  was  thought,  during  life,  to  be  suffering  from 
malignant  disease  of  the  pylorus.  As  far  as  I  know,  every  case  on  record 
in  which,  owing  to  a  biliary  fistula,  a  thickened  pylorus  existed,  has, 
in  the  same  way,  been  wrongly  diagnosed.  It  should  not  be  forgotten 
that  the  formation  of  a  fistula  may  open  a  vessel  and  lead  to  considerable 
haemorrhage. 

Intestinal  obstruction  due  to  gallstone  is  treated  of  under  the 
subject  of  intestinal  obstruction  generally.  Here  the  only  points  which 
call  for  notice  are,  that  often  the  ulceration  of  a  stone  from  the  gall  bladder 
into  the  intestine  is  unaccompanied  by  either  jaundice  or  pain,  but  nearly 
always  a  history  of  previous  attacks  of  colic  can  be  obtained ;  that  obstruc- 
tion is  less  likely  if  it  passes  straight  into  the  colon  than  if  it  goes  into 
the  intestine,  for  the  obstruction  nearly  always  takes  place  a  little  above 
the  ileo-ceecal  valve.  It  is  said  to  be  a  point  in  diagnosis  that,  although 
the  obstruction  appears  otherwise  complete,  and  feecal  vomiting  may  be 
present,  yet  flatus  may  be  passed ;  but  I  am  certain  this  is  also  true  of 
growth,  and  as  most  of  the  patients  are  elderly,  and  the  obstruction  is  chronic, 
having  lasted  usually  rather  over  a  week,  the  diagnosis  commonly  lies 
between  growth  and  gallstone.  In  the  last  case  under  my  care,  as  careful 
cross-questioning  failed  to  reveal  any  history  of  colic,  we  regarded  the  case 
as  one  of  growth ;  but  a  gallstone  was  found  a  little  above  the  ileum,  and, 
on  subsequent  inquiry,  the  patient's  friends  said  she  had  misinformed  us,  as 
she  had  previously  suffered  from  gallstones. 

Biliary  cirrhosis. — The  teaching  of  Charcot  and  others  has  called 
wide  attention  to  the  view  that  obstruction  to  the  flow  of  bile  will  set  up 
cirrhosis  of  the  liver,  and  that,  consequently,  the  impaction  of  calculi  will 
lead  to  cirrhosis.  Ligature  of  the  common  duct  will,  in  animals,  cause  a 
diffuse  cirrhosis,  and  this  may  also  sometimes  be  found,  after  death,  in 
persons  who  have  had  biliary  obstruction.  When  present,  it  is  always  of 
the  hypertrophic  variety.  A  further  discussion  on  this  subject  will  be 
found  in  the  article  on  Cirrhosis  of  the  Liver.  We  need  only  state  here  that 
biliary  cirrhosis  is  never  well  enough  marked  to  give  rise  to  symptoms 
during  life.  It  is  a  condition  recognised  in  the  post-mortem  room,  but  not 
in  the  wards. 

Carcinoma  of  the  bile  passages. — Hilton  Fagge  was  the  first  in  this 
country  to  point  out  that  gallstones  frequently  lead  to  carcinoma,  and 
Naunyn  quotes  124  cases  of  carcinoma  of  the  gall  bladder,  and  in  114 
gallstones  were  present.  The  growth  may  be  either  hard,  soft,  alveolar,  or 
villous.  From  the  cases  I  call  to  mind,  the  gall  bladder  is  usually  shrunken, 
and  does  not  project  from  the  under  surface  of  the  liver,  although  its  walls 
are  thickly  infiltrated  with  growth ;  its  cavity  is  much  reduced,  and  con- 
tains gallstones  and  a  little  brown  fluid.  On  the  other  hand,  if  the  growth 
is  chiefly  confined  to  the  neck,  then  the  gall  bladder  distends  and  forms  a 
large  mass  projecting  from  the  under  surface  of  the  liver  ;  and,  in  other 
rare  cases,  the  growth  itself  may  project  as  a  tender  mass  from  the  under 
surface  of  the  liver.  Whether  it  has  begun  in  the  bladder,  or  in  one  of  the 
ducts,  it  often  spreads  along  these.  Quite  commonly,  too,  it  extends  by 
continuity  into  the  hepatic  substance,  and  it  may  grow  into  the  colon ;  but 
I  should  certainly  agree  with  the  statement  that  genuine  secondary  meta- 
static growths  in  the  liver  are  not  as  common  in  those  cases  in  which 
the  primary  growth  is  in  the  gall  bladder,  as  in  those  in  which  it  is  in 
some  other  organ  at  the  periphery  of  the  portal  system.  Owing  to  the 
frequency  with  which  a  gallstone  is  impacted  at  the  duodenal  portion  of 


766  ALIMENTAR  Y  S  YSTEM. 

the  common  duct,  that  is  a  common  seat  of  growth,  and  it  is  quite  possible 
that  some  growths,  thought  to  be  primary,  in  the  head  of  the  pancreas, 
really  originate  here.  Whatever  may  be  the  primary  seat,  the  glands  in 
the  transverse  fissure  may  be  enlarged,  and  if  they  press  upon  the  common 
duct  and  portal  vein,  then  jaundice  and  ascites  may  follow.  Lastly,  in 
some  cases  the  peritoneum  may  become  infected.1 

Diagnosis. — There  is  no  condition  which  is  especially  often  confused 
with  gallstone  colic,  but  in  some  cases  care  will  have  to  be  exercised  to 
distinguish  it  from  the  other  painful  abdominal  diseases.  The  jaundice 
from  the  so-called  catarrhal  jaundice,  does  not  usually  subside  so  quickly 
as  does  that  due  to  gallstones. 

Treatment. — During  an  attack  of  gallstone  colic,  morphine  should  be 
injected  subcutaneously  till  the  pain  is  eased.  Many  like  to  use  a  mixture 
of  morphine  with  a  little  atropin.  Hot  fomentations  should  be  frequently 
applied  over  the  region  of  the  gall  bladder,  and  the  patient  may  be  given 
plenty  of  hot  water  to  drink ;  for  although  she  will,  because  of  the 
vomiting,  quickly  return  it,  after  this  has  happened  several  times  it  is 
usually  retained,  and  she  is  not  more  sick  with  the  hot  water  than  she 
wTould  be  without  it.  Great  relief,  too,  is  said  to  follow  when  hot  water  is 
thrown  high  up  into  the  large  bowel  in  considerable  quantities.  If  the 
pain  is  very  severe,  the  patient  may  inhale  about  as  much  chloroform  as  is 
used  to  relieve  the  pains  of  labour.  Some  advise  a  dose  of  30  or  40  grs.  of 
salicylate  of  sodium,  but  it  is  hardly  likely  that  it  will  be  retained. 

Between  the  attacks,  our  object  is  to  hurry  the  flow  of  bile,  in  order 
to  prevent  the  formation  of  fresh  calculi,  and  to  move  on  any  that  may 
be  present.  For  this  purpose,  the  movements  of  the  lower  part  of  the 
thorax  should  be  free,  and  no  stays  or  other  tight  clothing  should  be  worn ; 
the  patient  should  take  plenty  of  outdoor  exercise,  of  which  riding  and 
hill-climbing  are  perhaps  the  best  forms ;  and  as  active,  healthy  digestion 
favours  the  flow  of  bile,  the  food  should  be  restricted  to  a  simple  mixed 
diet,  and  it  is  important  that  enough  food  should  be  taken,  and  the  patient 
should  not  go  too  long  without  it.  But  excess  and  improper  food,  as  they 
lead  to  indigestion,  should  be  especially  avoided,  and  it  appears  that 
carbohydrates  are  not  at  all  well  digested.  Active  intestinal  movements 
favour  the  flow  of  bile,  and  although  the  experimental  evidence  that  most 
of  the  so-called  cholagogues  increase  the  biliary  flow  is  slight,  still,  as  these 
patients  usually  require  aperients,  drugs  such  as  euonymin,  calomel, 
powdered  ipecacuanha,  podophyllin  or  iridin,  which  are  commonly  classed 
as  cholagogues,  may  be  used ;  but  clinical  experience  goes  to  show  that  the 
best  aperient  cholagogue  for  these  patients  is  sulphate  of  sodium,  from 
which  it  follows  that  it  is  excellent  treatment  to  give  at  night  a  pill 
containing,  say,  1  gr.  of  calomel,  1  of  euonymin,  and  \  gr.  of  powdered 
ipecacuanha,  followed,  in  the  morning  by  such  a  quantity  of  a  sidphate  of 
sodium  water — such  as  Friedrichshall,  yEsculap,  Pulna,  or  Hunyadi  Janos — 
that,  when  mixed  with  half  a  tumbler  of  warm  water  and  sipped  during 
dressing,  it  will  ensure  that  the  bowels  are  well  opened  after  breakfast.  I 
have  found   a  mixture  of  JEsculap  and  Hunyadi  Janos  very  efficacious. 

1  Recent  experience  has  shown  that  "simple  infective  cholangitis  "  is  a  sufficiently  frequent 
complication  of  gallstones  to  merit  description  here.  The  chief  symptoms  are  hepatic  pain, 
jaundice,  sometimes  s-vere,  but  often  slight  and  variable,  an  enlarged  and  tender  liver,  rigors, 
sweating,  vomiting  and  pyrexia,  lasting  for  many  days  or  weeks  'without  the  formation  of 
abscesses  in  the  liver.  Patients  may  for  many  years  be  subject  to  these  attacks.  Sometimes 
it  is  necessary  to  cut  out  the  stone  from  the  common  duct,  but  often  the  patients  recover 
■without  operative  interference. 


DISEASES  OF  THE  LIVER.  767 

Salicylate  of  sodium  favours  the  secretion  of  bile,  and  therefore  5  or  10  gr. 
of  this  should  be  taken  thrice  a  day.  It  has  already  been  mentioned  that 
cholesterin  is  peculiarly  soluble  in  olein,  and  Brockbank  has  shown  that 
when  a  gallstone  is  placed  in  olive  oil,  and  maintained  at  the  temperature 
of  the  body,  it  loses  68  per  cent,  of  its  weight  in  ten  days.  Many 
observers,  too,  claim  that  distinct  benefit  follows  the  administration  of 
large  amounts  of  olive  oil.  I  certainly  have  seen  patients  improve  while 
taking  it.  Probably  the  administration  of  olive  oil  leads  to  the  excretion 
of  some  of  its  olein  in  the  bile,  but  experimental  evidence  on  this  point  is 
wanting.  Some  patients  will  not  take  it  at  all,  others  take  it  neat.  A 
little  lemon-juice  often  makes  it  palatable,  or  it  may  be  given  with  salad,  or 
mashed  up  with  either  fish  or  potatoes.  The  patient  should  try  to  take  at 
least  5  oz.  a  day,  and  may  take  8  or  10.  If  she  cannot  take  much  of  the 
oil,  she  may  eat  plenty  of  butter  and  fat,  and  use  cream  in  her  tea.  Firm 
abdominal  massage  in  the  hepatic  region  is  often  useful,  and  if  ordinary 
exercise  cannot  be  obtained,  gymnastics  may  be  substituted.1 

There  is  no  doubt  that  sufferers  from  gallstone  colic  derive  great  benefit 
from  going  to  places  where  hot  sulphate  and  carbonate  of  sodium  springs 
exist.  As  the  patients,  in  addition  to  being  given  the  water,  are  carefully 
dieted  and  take  exercise,  it  is  quite  in  accord  with  what  has  been  said  that 
they  should  do  well.  Carlsbad  is  by  far  the  most  popular  resort,  and  many 
patients  derive  very  great  benefit  from  a  visit  there.  It  is  usual  to  go  in 
the  summer.  The  waters  contain  sulphate,  bicarbonate,  and  chloride  of 
sodium,  and  their  temperature  as  they  leave  the  springs  is  between  122° 
and  158°  F.  Many  patients  go  to  Vichy  (temperature  of  water,  112°  F.), 
Ems  (114°  F.),  and  Neuenahr  (95°  F.).  All  these  waters  contain  bicarbonate 
of  sodium.  Eoyat  has  similar  warm  springs.  The  waters  of  Marienbad 
and  Leamington  both  contain  much  sulphate  of  sodium,  but  they  are 
not  hot. 

If  there  is  an  empyema  of  the  gall  bladder,  or  an  abscess  around 
it,  the  treatment  is  the  same  as  for  an  abscess  of  the  liver  (q.v.).  If, 
either  by  rupture  or  spread  of  inflammation,  acute  peritonitis  has  been 
set  up,  the  peritoneum  should  be  thoroughly  cleansed.  If  the  patient 
has  suffered  from  repeated  attacks  of  biliary  colic,  which  are  wearing 
out  his  strength,  and  have  not  yielded  to  medical  treatment,  or  if  he 
has  persistent  jaundice  from  obstruction  of  the  common  duct,  or  if  the 
gall  bladder  is  so  distended  that  it  forms  a  painful  tumour,  which  may 
rupture,  the  question  of  surgical  interference  should  be  carefully  considered. 
Either  the  obstruction  may  be  removed,  or  a  commuincation  may  be 
established  between  the  gall  bladder  and  some  part  of  the  intestine.  Stones 
from  the  gall  bladder  are  easily  evacuated  when  it  is  opened  (chole- 
cystotomy).  This  is  best  done  by  an  incision  in  the  right  semilunar  line, 
beginning  at  the  costal  margin.  If  there  is  no  reason  for  hurry,  the  gall 
bladder  may  be  stitched  to  the  margins  of  the  wound  in  the  abdominal  wall 
before  it  is  opened,  and  whenever  it  is  opened  the  wound  should  be  carefully 
packed  to  prevent  any  extravasation  of  bile  into  the  peritoneal  cavity. 
Stones  in  the  cystic  duct  may,  after  the  gall  bladder  is  opened,  be  extracted 
by  forceps  or  scoop,  and  i  f  they  are  very  firmly  fixed  it  may  be  necessary 
to  first  crush  them.  If  the  obstruction  has  been  removed,  bile  will  pass 
the  natural  way,  and  the  opening  in  the  gall  bladder  will  close  up.  When 
the  stone  is  in  the  common  duct,  the  case  is  more  difficult  to  manage.     The 

1  Eunahol,  which  is  pure  oleate  of  sodium,  has  been  given  in  doses  of  30  or  40  grs.  without 
success. 


768  ALIMENTAR  Y  S  YSTEM. 

duct  may  be  incised,  the  stone  turned  out,  and  the  wound  in  the  duct 
stitched  up  again ;  or  it  may  be  crushed  between  the  finger  and  thumb  or 
with  padded  forceps,  or  it  may  be  broken  by  a  needle,  and  the  pieces  left 
to  discharge  into  the  duodenum.  When  the  obstruction  cannot  be  removed, 
the  gall  bladder  may  be  made  to  communicate  with  the  intestine  (cholecyst- 
enterostomy).  The  directions  given  by  Treves  are  as  follow  : — The 
abdomen  is  opened  in  the  right  semilunar  line,  and  the  gall  bladder  is 
exposed.  The  nearest  loop  of  the  upper  jejunum  is  now  brought  up,  and  is 
fixed  to  the  gall  bladder  by  a  row  of  sutures,  arranged  in  a  circle,  and 
enclosing  an  area,  if  possible,  equal  to  the  lumen  of  the  bowel.  The  gall 
bladder  is  now  opened  and  emptied,  and  through  this  opening  a  communi- 
cation is  made  between  the  gall  bladder  and  the  bowel  within  the  area 
embraced  by  the  suture  line.  If  necessary,  a  few  additional  sutures  are 
inserted.  Then  the  opening  in  the  gall  bladder  and  that  in  the  abdominal 
wall  are  closed.  The  operation  may  be  done  in  stages — (1)  The  unopened 
gall  bladder  and  unopened  bowel  are  united  by  sutures  ;  (2)  the  gall  bladder 
is  opened,  and  then  an  incision  is  made  from  it  into  the  bowel ;  (3)  the 
incision  into  the  gall  bladder  is  closed.  Murphy's  button  is  often  used 
in  this  operation.  It  may  be  necessary  to  excise  the  gall  bladder 
(cholecystectomy).  Mayo  Eobson  says  this  may  be  done  when,  after 
cholecystotomy,  the  gall  bladder  is  so  contracted  or  softened  that  it  cannot 
be  sutured,  and  the  common  duct  is  patent,  or  when  the  cystic  duct  is  com- 
pletely obliterated.  None  of  these  operations  should  be  undertaken  lightly. 
They  are  often  very  difficult 


ACTIVE  HYPEE^MIA  OF  THE  LIYEE. 

Venous  distension  of  the  liver,  secondary  to  disease  of  the  heart  and 
lungs,  will  be  described  later ;  but  the  quantity  of  blood  in  the  liver  may 
be  increased  in  other  ways.  For  instance,  after  each  meal  the  organ 
is  engorged,  and  it  is  quite  likely  that  the  dyspepsia  which  occurs  in 
those  who  eat  and  drink  too  much  may  be  associated  with,  and  increased 
by,  a  lasting  over-distension  of  the  hepatic  vessels,  and  this  may  be  the 
cause  of  the  sense  of  fulness  and  distension  in  the  hepatic  region  of  which 
these  persons  complain.  They  usually  suffer  from  nausea,  loss  of  appetite, 
a  furred  tongue,  headache,  constipation,  and  often  an  unusual  drowsiness. 
A  more  limited  and  simple  diet  and  a  cholagogue  purge  generally  benefit 
them ;  and,  to  prevent  further  attacks,  they  should  lead  an  active  life,  with 
plenty  of  exercise,  and  should  be  moderate  and  simple  in  their  eating  and 
drinking.  From  time  to  time  they  will  require  a  purgative,  and  that 
combination  already  recommended  for  patients  suffering  from  gallstones 
will  be  found  most  suitable. 

Those  who  practise  in  tropical  climates,  especially  India,  are  familiar 
with  a  much  more  severe  form  of  congestion  of  the  liver,  which  occurs 
among  Europeans  living  in  these  climates.  This  condition  is  usually 
ascribed  to  the  excessive  heat,  together  with  over-indulgence  in  alcohol  and 
food.  At  first  the  patient  often  has  a  little  diarrhoea,  his  liver  is  enlarged 
and  tender,  and  there  is  considerable  pain  and  heaviness  under  the  right 
ribs ;  he  is  slightly  jaundiced,  but  as  the  months  go  on  he  becomes  anaemic 
and  sallow;  he  suffers  from  constipation,  with  pale  motions ;  his  digestion  is 
poor,  and  the  enlargement  of  the  liver  becomes  permanent.  Men  suffer 
much  more  than  women,  probably  because  they  eat  and  drink  more.     Of 


DISEASES  OF  THE  LIVER.  769 

late  years  the  number  of  persons  in  India  suffering  from  diseases  of  the 
liver  has  been  diminishing,  probably  because  less  alcohol  is  drunk  than 
formerly.  If  an  opportunity  occurs  at  the  early  stage  of  this  disease  of 
seeing  the  liver,  it  is  found  to  be  intensely  congested ;  later,  it  is  harder  and 
denser  than  in  health.  It  may  be  necessary  for  these  patients  to  give  up 
riving  in  tropical  climates.  They  must  always  be  very  careful  and 
moderate  in  the  matter  of  eating  and  drinking,  and  the  bowels  should  be 
kept  carefully  open. 


DISEASES   OF  THE   POETAL  VEIN. 

The  most  important  affection  of  the  portal  vein  is  thrombosis.  Its 
most  common  causes  are  the  extension  into  the  vein  of  a  nodule  of 
malignant  disease,  growing  either  in  the  liver,  pancreas,  or  glands  in 
the  transverse  fissure,  and  cirrhosis  of  the  liver.  Occasionally  the 
condition  seems  associated  with  perihepatitis,  and  sometimes  there  is 
nothing  to  suggest  a  cause.  The  clot  may  occupy  the  whole  or  only 
a  part  of  the  calibre  of  the  vein,  and  in  cirrhosis  the  patient  may  live 
long  enough  for  the  clot  to  completely  organise,  and  then  to  shrink  so 
that  the  walls  of  the  portal  vein  come  in  contact  with  one  another.  The 
vein  is  replaced  by  an  impervious  narrow  cord,  and  we  have  then  the 
condition  known  as  pylephlebitis  adhesiva.  This  is  excessively  rare;  it 
may  be  associated  with  frequently  recurring  ascites,  but  this  is  by  no  means 
always  the  case.  No  doubt,  when,  as  usual,  portal  thrombosis  extends  up 
to  the  liver,  the  circulation  is  chiefly  carried  on  by  anastomosis  between 
the  portal  and  general  venous  systems  ;  the  mesenteric  and  splenic 
veins  are  much  enlarged  in  one  of  our  museum  specimens.  In  dogs, 
when  a  ligature  is  applied  to  the  portal  vein,  there  is  dilatation  of  the 
anastomosis  between  the  branches  of  the  portal  vein,  which  enter  it 
above  and  below  the  ligature,  very  little  ascites  develops,  and  the  animal 
seems  none  the  worse  for  the  ligature.  Considering  the  large  size  of  the 
portal  vein,  and  the  sudden  obstruction  of  a  ligature,  the  absence  of  ascites 
can  hardly  be  explained  by  the  anastomosis.  There  is  a  specimen  in  the 
Guy's  Museum,  in  which  an  aneurysm  of  the  portal  vein  is  associated  with 
thrombosis  of  it.  Thrombosis  of  the  portal  vein  is,  except  in  the  very  rare 
pylephlebitis  adhesiva,  of  little  clinical  interest,  and,  indeed,  we  are  first 
made  aware  of  it  at  a  post-mortem  examination ;  but  it  may  be  associated 
with  hamiatemesis.  Suppurative  pylephlebitis  will  be  described  in  speaking 
of  py£emia. 

DISEASES   OF   THE  HEPATIC  AETEEY. 

Aneurysms  of  this  artery  are  very  rare.  The  symptoms  which  have 
been  noted  are  pain,  jaundice,  and  a  tumour.  A  patient  under  my  care 
had  an  aneurysm  of  each  hepatic  artery ;  the  only  symptom  which  could  be 
set  down  to  them  was  jaundice.  These  aneurysms  usually  rupture  into  the 
peritoneal  cavity,  but  they  may  burst  into  the  bile  passages.  Usually  they 
are  infective. 


vol.  1. — 49 


7  7  o  ALIMENTAR  Y  S  YSTEM. 


ABSCESS  OF  THE  LIVER. 

For  clinical  purposes  these  are  best  divided  into  two  groups — multiple 
small  abscesses,  and  solitary — in  rare  cases  two  or  even  three  may  be 
present  at  the  same  time — large  abscesses. 

Multiple  Small  Abscesses. 

These  are  always  pyaemic,  and  usually  the  source  of  infection  is  at 
the  periphery  of  the  portal  vein.  Thus  they  are  found  after  ulcer  of 
the  stomach,  ulceration  of  the  intestine  and  fistula,  operations  for  piles, 
suppuration,  or  ulceration  of  the  biliary  channels,  abscesses  in  the  spleen, 
disease  of  the  pancreas,  appendicitis,  and  diseases  of  the  female  pelvic 
organs.  In  rare  cases,  multiple  pyaemic  abscesses  are  found  in  the  liver 
as  a  result  of  general  pyaemia. 

Morbid  anatomy  and  pathology. — When  infection  of  the  liver 
takes  place  through  the  portal  vein,  infective  emboli  are  taken  by  it  to  the 
liver,  and  block  the  minute  twigs  of  the  portal  vein,  the  liver  becomes 
studded  with  small  patches  of  necrotic  tissue,  and  very  quickly  numbers 
of  abscesses  form ;  they  are  usually  about  the  size  of  peas,  but  they  may, 
however,  be  as  large  as  a  Tangerine  orange.  No  gangrene  of  the  liver 
is  ever  observed,  and  the  patient  almost  always  dies  before  an  abscess 
ruptures  into  the  peritoneal  cavity  or  an  adjacent  viscus,  but  contiguous 
abscesses  may  run  one  into  the  other,  and  pus  may  be  found  in  the 
hepatic  veins.  It  is  common,  too,  in  cases  of  portal  pyaemia,  to  find  pus  in 
the  portal  vein,  and  there  is  often  also  an  acute  phlebitis  of  it,  together 
with  much  attached  ante-mortem  clot,  and  this  condition  is  called  acute 
pylephlebitis.  In  very  rare  instances,  in  which  the  infective  material  is 
only  slightly  toxic,  pylephlebitis  may,  like  acute  inflammation  of  other 
veins,  recover ;  then,  as  in  other  veins,  the  vessel  becomes  permanently 
occluded  and  even  converted  into  a  fibrous  cord ;  this  condition  is  called 
pylephlebitis  adhesiva  (see  "  Thrombosis  ").  It  is  highly  improbable  that 
there  are  any  abscesses  in  the  liver  in  those  cases  which  recover.  In  a 
few  instances  of  multiple  pyaemic  abscesses  of  the  liver,  the  source  of  infection 
is  at  the  distal  end  of  some  branches  of  the  general  venous  system.  This 
is  difficult  to  understand,  for  before  the  infective  emboli  can  reach  the 
liver  they  must  traverse  the  lungs,  and  it  is  not  easy  to  explain  why  they 
should  be  able  to  pass  the  lungs  and  yet  be  arrested  in  the  liver;  it 
will  not  do  to  suppose  that  the  liver  is  infected,  from  abscesses  in  the  lungs 
set  up  by  the  original  infection,  for,  according  to  Wilks  and  Moxon,  the 
abscesses  in  the  liver  may  appear  older  than  those  in  the  lungs ;  even 
in  cases  in  which  the  infection  might  be  expected  to  come  from  the  lungs 
or  the  left  side  of  the  heart,  pysemic  abscesses  of  the  liver  are  very  rare,  for, 
owing  to  the  free  anastomosis  between  the  portal  and  hepatic  capillaries, 
it  is  very  difficult  to  produce  infarction  of  the  hepatic  artery. 

Symptoms. — Although  we  can  usually,  from  the  presence  of  rigors, 
sweating,  and  the  other  signs  of  pyaemia,  make  out  that  the  patient  is 
suffering  from  this  disease,  yet  there  are  hardly  ever  any  local  signs 
indicating  that  the  liver  is  affected  with  multiple  pyaemic  abscesses. 

Prognosis  and  treatment. — It  need  hardly  be  added  that  the 
prognosis  of  multiple  pyaemic  abscesses  of  the  liver  is  very  bad,  and  that 
no  local  treatment  for  the  hepatic  condition  is  possible. 


DISEASES  OF  THE  LIVER.  771 


Single  Lakge  Abscesses. 


These,  which  are  almost  always  single,  and  never  numerous,  naturally 
fall  into  certain  groups  which  may  best  be  considered  from  an  etiological 
standpoint. 

Etiology. — The  tropical  abscess  is  often,  but  by  no  means  always, 
associated  with  dysentery  (tropical  abscesses  of  the  liver  are  found  in 
about  20  per  cent,  of  the  cases  of  dysentery,  and  Kelsch  and  Kiener 
state  that  dysentery  occurs  in  75  per  cent,  of  cases  of  tropical  hepatic 
abscess),  so  that  they  have  been  said  to  be  pysemic,  and  due  to  absorption 
from  dysenteric  ulcers.  This  is  incorrect,  for  we  have  seen  that  the  ordinary 
pysemic  abscess  of  the  liver  is  multiple  and  small,  not  solitary  and  large ; 
and  further,  in  many  cases  of  dysentery,  typical  pysemic  abscesses  of  the 
liver  are  found — presumably  due  to  pysemic  infection  through  the 
dysenteric  ulcers — and  these  may  even  be  associated  in  the  same  liver 
with  the  large  tropical  abscess.  Then  the  amoeba,  which  many  observers 
believe  to  be  the  cause  of  dysentery  (q.v.),  has  been  found  in  the  pus  of 
these  large  hepatic  abscesses ;  and  it  is  quite  possible  that  when  the  large 
hepatic  abscess  is  unassociated  with  dysentery,  that  the  dysenteric  amoeba 
has  gained  entrance  into  the  portal  vein  without  causing  dysenteric  ulcers 
in  the  intestine,  just  as  the  scolices  of  the  Tcenia  echinococcus  may  gain  an 
entrance  into  this  vein  without  exciting  any  reaction  at  the  point  of 
entrance.  If  it  is  urged  that,  on  this  view,  it  is  strange  that  tropical 
abscesses  should  usually  be  solitary,  and  never  exceed  one  or  two,  we 
must  remember  that  usually  there  is  only  one  hydatid  in  the  liver.  But 
although  for  the  above  reasons,  derived  from  morbid  anatomy,  there  is  no 
doubt  that  the  large  abscess  is  not  pysemic,  and  is  frequently  associated 
with  dysentery,  yet  the  bacteriology  of  the  subject  is  far  from  complete, 
for  authors  are  not  yet  unanimous  that  the  amoeba  coli  is  the  cause  of 
dysentery ;  some  have  failed  to  find  it  in  the  pus  of  tropical  abscess, 
although  they  have  found  many  other  organisms,  as  streptococci, 
staphylococci,  and  B.  coli,  while  others  again  have  reported  that 
the  pus  is  sterile,  but  this  statement  does  not  exclude  the  amoeba. 
The  frequency  of  tropical  abscess  is  lessening.  This  is  attributed  to  better 
sanitation  and  less  indulgence  in  large  meals  and  alcohol.  In  English 
practice  these  abscesses  are  usually  found  in  those  who  have  resided  in 
the  tropical  parts  of  India  and  the  East  Indies,  but  they  also  occur  in 
persons  coming  from  other  tropical  regions,  as  the  Southern  States  of 
America. 

Large  abscesses  closely  resembling  tropical  abscesses  may  in  rare  in- 
stances occur  in  those  who  have  never  left  England.  Sometimes  these 
are  associated  with  ulcerative  colitis,  as  in  a  case  I  recorded  in  1894,  and 
other  cases  are  given  by  Fagge  and  Dickinson.  Such  cases  certainly 
suggest  that  there  is  some  special  micro-organism  responsible  for  the 
ulcerative  colitis,  which,  being  taken  up  by  the  portal  vein,  causes  the 
hepatic  abscess.  A  hydatid  may  suppurate,  and  thus  be  the  cause  of  a 
hepatic  abscess.  A  blow  in  the  hepatic  region  may  cause  an  abscess  in 
the  liver,  but  it  sometimes  leads  to  an  abscess  between  the  liver  and 
diaphragm.  Suppuration  may  occur  around  foreign  bodies  embedded  in 
the  liver ;  thus  a  round  worm  has  been  found  in  the  centre  of  an  abscess. 
In  very  rare  instances  a  hepatic  abscess  is  due  to  the  spreading  into  the 
liver  of  some  neighbouring  suppuration.  Suppuration  of  the  gall  bladder, 
suppuration  around  a  gallstone,  and  suppuration  of  the  bile  ducts  (suppur- 


7  7  2  ALIMENT  A  R  Y  S  YSTEM. 

ating  cholangitis)  leading  to  abscesses  in  the  liver  have  been  described 
under  the  head  of  Gallstones.  Occasionally  we  meet  with  suppuration  of 
the  gall  bladder  which  is  independent  of  gallstones. 

Morbid  anatomy. — The  whole  liver  is  usually  enlarged,  congested, 
and  a  little  soft.  The  abscess  may  contain  several  pints  of  pus,  and  I  have 
seen  it  so  large  that  the  hepatic  tissue  was  a  mere  shell.  Its  cavity  is 
irregular,  and  has  ragged  walls  with  shreds  of  dead  liver  tissue  attached  to 
it ;  the  liver  tissue  immediately  around  it  is  hypersemic  and  soft,  although, 
if  the  abscess  has  lasted  some  time,  it  may  have  a  thick  well-defined 
capsule ;  the  pus  is  often  of  an  anchovy  paste  colour,  due  to  the  admixture 
with  it  of  disintegrated  hepatic  tissue.  A  suppurating  hydatid  is  shut  off 
by  its  capsule  from  the  surrounding  hepatic  tissue ;  therefore  its  limits  are 
always  sharply  marked,  and  the  pus  is  always  yellow.  If  the  abscess  is 
opened  or  discharges  naturally,  it  may  heal,  leaving  a  cicatrised  scar  in  the 
liver. 

Symptoms. — Occasionally  hepatic  abscesses  are  found  in  the  post- 
mortem room,  when  there  were  no  indications  during  life  of  their  presence, 
but  usually  the  first  symptoms  are  those  of  fever ;  the  temperature  is  raised, 
the  pulse  quickened,  and  the  patient  feels  out  of  sorts.     It  is  important  to 
notice  that  throughout  the  whole  course  of  the  disease  the  temperature 
chart  is  often  very  like  one  belonging  to  a  patient  suffering  from  ague,  for 
the  temperature  may  rise  to  104°  or  more,  and  suddenly  fall  to  normal,  with 
equal  periods  between  each  rise ;  sweating,  too,  may  be  very  marked ;  and 
mistakes  between  ague  and  hepatic  abscess  are  by  no  means  rare,  for  signs 
specially  pointing  to  the  liver  are  often  absent  when  the  abscess  is  small 
and  deep-seated.     But  in  most  cases  the  liver  sooner  or  later  enlarges,  and 
as  the  abscess  approaches  the  surface,  the  enlargement  becomes  irregular 
and  the  shape  of  the  organ  is  distorted.     As  it  is,  most  often  at  the  upper 
and  back  part  of  the  right  lobe  we  get  a  dome-shaped  increase  of  the 
hepatic  dulness   in  the  axillary  or  scapular  line,  with  perhaps  later  on 
some  bulging  of  the  right  lower  ribs  and  signs  of  compression  of  the  lung. 
The  lower  edge  of  the  organ  is  pushed  down  and  can  be  felt  easily  below 
the  ribs,  and  if  the  abscess  is  mostly  on  the  front  of  the  right  lobe,  we  may 
feel  a  lower  prominence  through  the  abdominal  wall,  and  the  lower  edge 
of   the   liver   becomes   further   removed   from   the   abdominal  wall,  and 
intestine  may  come  in  front  of  it,  and  then  a  mistake  as  to  the  size  of  the 
organ  is  very  easy.     When  the  abscess  is  quite  close  to  the  lower  edge,  this 
uf  course  becomes  very  rounded.     If  there  is  actual  bulging,  the  prominence 
is  tense,  rounded,  smooth,  free  from  any  inequalities,  and  fluctuation  may 
sometimes  be  detected.     Pain  and  tenderness  are  often  absent.     If  the 
pain  is  acute  and  tearing,  it  indicates  that  the  abscess  is  near  the  surface, 
and  perihepatitis  has  supervened ;  but  if  the  pain  is  dull  and  heavy,  the 
pus  is  deep  in  the  organ.     Occasionally  there  is  pain  in  the  right  shoulder, 
and  there  may  be  a  hacking  reflex  cough ;  jaundice,  ascites,  oedema  of  the 
lower  extremities,  distension  of  the  superficial  veins  of  the  abdomen,  and 
enlargement   of   the   spleen,  are   not   distinguishing  features   of   hepatic 
abscess,  and  are  rare  in  the  course  of  it,  and  when  present  are  accidental 
complications  due  to  pressure  of  the  abscess.     Vomiting  is  not  uncommon ; 
the  urine  is  high  coloured  and  loaded  with  lithates ;  albuminuria,  if  present, 
is  usually  febrile.     Eight  pleurisy  is  not  a  rare  complication.     An  abscess 
of  the  liver  may  exist  many  months,  the  patient  then  becomes  extremely 
weak  and  wasted,  and  passes  into  the  hectic  condition,  and  finally  dies 
exhausted ;  but  if  untreated,  the  abscess  may  burst  into  the  right  pleura  or 


DISEASES  OF  THE  LIVER.  773 

into  the  right  lung;  it  may  discharge  externally  into  the  peritoneal  cavity, 
the  stomach,  the  duodenum,  the  transverse  colon,  or  the  biliary  passages. 
In  much  rarer  cases  it  has  been  known  to  open  into  the  pericardium,  the 
portal  vein,  the  vena  cava,  or  the  pelvis  of  the  kidney.  Occasionally  it 
causes  serious  haemorrhage,  because  it  lays  open  some  large  blood  vessel. 
Of  these  complications  the  bursting  into  the  right  pleura  and  right  lung 
are  most  common.  Both  are  usually  preceded  by  a  particularly  distress- 
ing cough,  and  when  discharge  takes  place  into  the  lung  the  pus  coughed 
up  is  brick-red  in  colour,  and  there  are  physical  signs  of  consolidation 
of  the  lung.  The  patient  may  recover  from  this  condition,  but  he  often 
di^s  from  exhaustion. 

Diagnosis. — The  difficulty  of  diagnosis  from  ague  has  been  men- 
tioned. The  examination  of  the  blood  will  help  us,  for  in  suppuration  we 
shall  notice  the  increased  leucocytosis,  and  in  ague  the  Plasmodium  malarias. 
An  empyema  can  usually  be  distinguished  by  noticing  that  the  upper 
limit  of  the  dulness  is  horizontal,  but  an  encysted  right-sided  empyema 
may  give  rise  to  great  difficulty.  It  is,  however,  very  rare.  Still  more 
difficult  is  the  distinction  between  a  hepatic  abscess  and  one  between  the 
diaphragm  and  liver.  Here  history  of  residence  in  the  tropics  will  be  a 
great  help,  and  the  pus  withdrawn  may  be  of  an  anchovy  paste  colour  and 
contain  dysenteric  amoebse ;  and  these  facts  also  aid  us  in  distinguishing 
between  an  abscess  of  the  liver  and  a  suppurating  hydatid.  Pyemic 
abscesses  of  the  liver  are  never  large  enough  to  cause  local  signs,  but  a 
deep-seated  non-pysemic  abscess  may  give  rise  to  none.  The  history  will 
then  be  our  best  help.  Lastly,  an  abscess  of  the  liver  may  be  easily 
confounded  with  the  intermittent  pyrexia  which  is  associated  with  gall- 
stones. 

Prognosis. — Unless  the  abscess  is  opened  artificially,  this  is  very  bad; 
at  least  80  per  cent,  of  the  cases  which  are  not  operated  upon  die,  those  that 
recover  mostly  discharge  through  the  lung.  Even  when  the  abscess  is 
opened,  the  patient  often  dies  from  exhaustion,  for  he  may  not  present 
himself  for  treatment  until  it  is  already  of  a  large  size. 

Treatment. — If  an  abscess  of  the  liver  is  suspected,  a  long  exploring 
needle  should  be  thrust  into  the  organ  at  the  point  at  which  it  is  thought 
the  pus  comes  nearest  to  the  surface,  and  this  operation  may  be  repeated 
two  or  three  times  if  the  first  exploration  fails  to  discover  pus.  When 
the  pus  has  been  found,  the  case  becomes  surgical  rather  than  medical, 
for  it  must  be  evacuated  as  soon  as  possible.  If  the  abscess  is  near  the 
surface  of  the  liver,  this  organ  is  probably  adherent  to  the  abdominal  wall, 
in  the  position  chosen  for  evacuation;  if  it  is  not,  the  liver  may  be  stitched 
to  the  abdominal  wall ;  and  if  the  wound  is  carefully  packed,  the  abscess 
may,  if  the  case  is  urgent,  be  opened  at  once ;  but  as  the  escape  of  pus  into 
the  peritoneal  cavity  would  be  an  extremely  grave  complication,  it  is 
better  if  possible  to  wait  a  few  days  till  adhesions  have  formed  and  then 
to  open  the  abscess.  When  the  abscess  has  been  opened,  any  septa  in  it 
should  be  broken  down  and  a  very  wide  drainage  tube  inserted.  If  the 
abscess  is  at  the  back,  the  attempt  must  be  made  to  open  it  without 
wounding  the  pleura  and  peritoneum ;  if  this  is  impossible,  it  may  be 
necessary  to  drain  the  abscess  through  the  pleural  cavity.  The  patient 
should  be  well  fed,  and  treated  on  general  principles. 


774  ALIMENTAR  Y  S  YSTEM. 

CIKRHOSIS   OF   THE   LIVER 

If  a  student  were  to  derive  his  knowledge  of  cirrhosis  of  the  liver  from 
the  wards  and  post-mortem  room,  he  would  soon  gain  an  accurate  con- 
ception of  the  disease ;  but  if  he  were  to  try  to  learn  solely  from  books,  it 
is  probable  that  the  more  he  read  the  more  confused  he  would  become.  I 
shall  therefore  first  give  a  description  of  the  disease  as  usually  seen,  and 
then  the  reader  will  be  in  a  better  position  to  understand  the  controversial 
points. 

Alcoholic   Cirrhosis. 

This  forms  one  of  the  commonest  hepatic  affections  of  temperate 
climates. 

Etiology. — Although  a  number  of  causes,  as  backward  pressure 
from  heart  disease,  that  will  be  mentioned  later,  may  induce  some  cirrhosis, 
yet  we  know  of  no  cause  operative  in  this  country,  other  than  alcohol,  which 
will  produce  such  a  degree  of  cirrhosis  that  it  will  either  give  rise  to 
symptoms,  or  after  death  alter  the  liver  to  such  a  degree  that  this  will  be 
easily  recognised,  on  macroscopical  examination,  as  considerably  cirrhotic. 
No  doubt  sometimes  (especially  in  children)  no  history  of  alcohol  can  be 
obtained,  but  then  none  of  the  other  factors  which  have  been  erroneously 
supposed  to  cause  well-marked  cirrhosis  are  present,  and  even  in  children  a 
very  careful  inquiry  will  often  show  that  alcohol  was  taken,  when  at  first 
this  is  denied.  We  know  nothing  as  to  the  causes  of  the  few  cases  of  well- 
marked  cirrhosis  not  due  to  alcohol.  Cirrhosis  is  most  common  between 
the  ages  of  30  and  60,  and  the  sufferers  from  it  are  not  often  drunk, 
but  take  small  quantities  of  alcohol  constantly  throughout  the  day.  The 
disease  is  about  equally  common  in  men  and  women. 

Morbid  anatomy. — The  chief  determining  causes  of  the  alterations 
in  the  physical  condition  of  the  liver  are  the  increase  of  fibrous  tissue  and 
fat,  and  the  atrophy  of  the  liver  cells.  The  first  makes  the  cirrhotic  liver 
very  hard  and  tough,  so  that  it  may  even  creak  when  cut  with  a  knife. 
The  new  fibrous  tissue  may  be  easily  visible  to  the  naked  eye ;  it  is  uniformly 
distributed  throughout  the  liver,  and  never  occurs  as  wide  radiating  bands, 
which  are  characteristic  of  syphilis.  When  it  is  around  the  lobules  it  is 
said  to  be  perilobular ;  if  areas  composed  of  several  lobules  are  formed  by 
the  fibrous  tissue,  it  is  multilobular ;  if  each  area  contains  one  lobule,  it  is 
monolobular;  and  if  individual  lobules  are  invaded,  it  is  intralobular  cirr- 
hosis. When  the  new  fibrous  tissue  contracts,  as  in  the  kidney,  so  in  the 
liver,  the  surface  of  the  organ  becomes  granular ;  but  frequently  the  con- 
tracting bands  of  fibrous  tissue,  being  further  apart  than  is  the  case  in  the 
kidney,  the  islets  of  projecting  liver  substance  are  larger,  and  in  such  cases 
the  organ  is  commonly  said  to  be  hobnailed,  and  its  edge  is  uneven.  The 
new  fibrous  tissue  is  grey,  and  the  islets  of  liver  substance  are  varying  shades 
of  yellow  and  brown,  according  to  the  relative  quantities  of  fat  or  bile  pigment 
in  them.  On  section,  the  same  contrast  of  grey  bands  and  yellow  fatty  islets 
is  seen.  The  new-formed  bands  are,  if  young,  made  up  chiefly  of  cells ;  if 
older,  they  are  fully-developed  fibrous  tissue.  They  are  supplied  with  blood 
from  new-formed  branches  of  the  hepatic  artery ;  but  as  they  contract  they 
slowly  obliterate  the  minute  branches  of  the  portal  vein,  which  are 
filled  with  clot,  because  of  the  retardation  of  the  current  in  them ;  and 
occasionally  the  portal  vein  itself  may  contain  an  ante-mortem  thrombus. 
The  bile  ducts  withstand  the  pressure  much  longer ;  indeed,  it  is  doubtful 


DISEASES  OF  THE  LIVER.  775 

whether  the  bile  staining  of  the  liver  is  clue  to  compression  of  them.  The 
pressure  exerted  on  the  islets  of  liver  tissue  is  so  considerable,  that  often 
when  the  liver  is  cut  they  at  once  rise  and  project  on  the  surface  of  the 
section;  slowly  they  may  undergo  complete  atrophy,  and  neighbouring 
bands  of  fibrous  tissue  by  their  coalescence  form  wider  bands.  Most 
authors  assume  that  the  degeneration  of  the  cells  is  secondary  to  the 
contraction  of  the  fibrous  tissue,  but  we  must,  as  Mott  points  out,  remember 
that  the  atrophy  of  the  cells  may  occur  before  the  fibrous  tissue  has  begun 
to  contract.  It  is  clear  that  the  size  of  a  cirrhotic  liver  must  be  very 
variable,  for  the  formation  of  embryonic  tissue  will  at  firsb  increase  it ;  but 
as  this  becomes  fibrous  and  contracts,  the  liver  will  diminish  in  size,  which 
diminution  will  become  more  marked  as  the  atrophy  of  the  liver  cells  sets 
in.  Then,  too,  the  amount  of  fat  in  a  cirrhotic  liver  is  of  great  importance 
in  determining  its  size  ;  all  very  large  cirrhotic  livers  contain  much  fat.  As 
a  result  of  these  varying  factors,  a  cirrhotic  liver  may  vary  in  weight 
between  2  and  9  lb.  Price  found  that,  out  of  130  cases  of  fatal  cirrhosis,  in 
nine  the  liver  weighed  less  than  40  oz.,  in  twenty  between  40  and  50,  in 
thirty-three  between  50  and  60,  in  thirty-one  between  60  and  80,  in  twenty- 
five  between  80  and  100,  in  ten  between  100  and  150,  and  in  two  over  150. 
That  is  to  say,  twenty -nine  livers  were  below  the  normal  weight,  thirty- 
three  were  of  the  normal  weight,  and  seventy-eight  were  above  it.  The 
peritoneum  over  the  liver  is  frequently  thickened  and  opaque,  and  there 
are  often  adhesions  to  the  abdominal  wall;  signs  of  general  chronic 
peritonitis  are  too  often  seen,  and  so  the  mesentery  is  occasionally 
retracted,  the  peritoneum  generally  may  be  opaque,  the  intestines  may  be 
welded  together  into  a  lump,  the  gut  may  be  shortened,  and  the  wall  of  it 
and  the  stomach  may  be  obviously  thickened.  The  spleen  and  pancreas 
are  usually  hard,  and  the  subjects  of  cirrhosis  may  have  a  fatty  heart, 
atheromatous  vessels,  granular  kidneys,  or  ©edematous  lungs. 

The  anastomoses  between  the  portal  and  general  venous  systems  are 
much  dilated.  By  far  the  most  important  are  those  between  the  middle 
and  inferior  hemorrhoidal,  and  between  the  gastric  and  oesophageal  veins. 
Others  exist  between  the  capsular  branches  of  the  portal  which  supply  the 
liver,  and  by  means  of  its  ligaments  communicate  with  those  of  the 
diaphragm  ;  between  the  portal  branches  which,  running  in  the  round  and 
suspensory  ligaments,  reach  the  umbilicus  and  anastomose  with  the  branches 
of  the  internal  mammary  and  epigastric  veins ;  between  the  portal  branches 
in  the  intestinal  walls,  and  branches  going  into  the  inferior  cava. 

Pathology. — It  is  erroneous  to  regard  cirrhosis  of  the  liver  as  a 
purely  local  disease  of  that  organ.  In  many  respects  it  reminds  us  of 
chronic  interstitial  nephritis.  In  both  diseases  we  have  a  similar  morbid 
anatomy,  and  many  symptoms  showing  that  the  effects  are  felt  far  beyond 
the  organ  chiefly  affected;  in  cirrhosis  there  are  the  sudden  onset  of 
ascites  (apart  from  any  sudden  increase  in  portal  obstruction),  the  frequent 
slight  chronic  peritonitis,  the  oedema  of  the  feet,  the  nervous  symptoms, 
the  changes  in  the  blood  (of  which  the  jaundice  is  possibly  an  expression), 
the  liability  to  haemorrhages,  and  the  pyrexia.  Of  these,  the  ascites, 
the  oedema  of  the  feet,  and  the  nervous  symptoms  are,  like  those  of 
uraemia,  liable  to  come  on  so  suddenly  that  we  can  hardly  help  supposing 
that  the  cirrhotic  liver  or  the  cirrhotic  kidney  has  suddenly  failed  to 
excrete,  or  has  suddenly  manufactured  some  poison,  which  is  usually  fatal, 
and  kills  probably  by  causing,  in  both  cases,  both  respiratory  and  cardiac 
failure  ;    in    both    diseases    it   appears   extremely   likely  that   the   more 


7  7  6  ALIMENT AR  Y  S  YSTEM. 

chronic  symptoms  are  also  toxic.  Lastly,  both  cirrhosis  of  the  liver  or 
kidney,  as  the  case  may  be,  is  often  found  after  death  when  its  presence 
was  quite  unsuspected  during  life.  Experiments  do  not  help  us  much  to 
understand  the  disease,  for  well-marked  cirrhosis  cannot  be  produced  by 
giving  alcohol  to  animals.  It  only  makes  their  liver  fatty.  This  is 
interesting  when  we  bear  in  mind  that  some  sufferers  from  cirrhosis  have 
not  taken  much  alcohol. 

Symptoms. — It  is  important  to  remember  that  cirrhosis  is  very 
frequently  found  post-mortem  in  persons  who  have  during  life  shown  no 
signs  of  it,  and  sometimes  in  these  cases  the  liver  is  small,  and  this  suggests 
that  the  disease  has  been  present  some  time.  Animals  in  whom  the  portal 
vein  is  led  directly  into  the  inferior  vena  cava,  may  live  a  long  time,  so  that, 
when  the  liver  is  slowly  destroyed  by  cirrhosis,  it  is  not  surprising  that  the 
patients  may  survive,  especially  as  the  destruction  of  liver  tissue  is  never 
complete,  and  no  symptoms  need  arise  from  the  obliteration  of  minute 
branches  of  the  portal  vein  if  the  collateral  circulation  is  well  maintained. 

Physical  examination. — If  the  liver  is  enlarged,  this  may  often  be 
made  out  both  by  percussion  and  palpation  ;  and  even  if  ascites  is  present, 
the  liver  may  be  felt  by  suddenly  pressing  down  on  it ;  the  lower  margin 
may  be  at  the  umbilicus,  or  lower ;  the  surface  can  often  be  felt  to  be  hard 
and  hobnailed ;  and  the  lower  edge,  too,  is  hard  and  somewhat  uneven.  Some- 
times, even  when  the  organ  is  not  enlarged,  this  characteristic  edge  may  be 
felt,  if  the  fingers  be  thrust  well  under  the  ribs  and  the  patient  inspires 
deeply.  On  the  other  hand,  it  is  often  impossible  to  feel  the  organ,  and 
the  hepatic  dulness  on  the  chest  wall  may  be  diminished.  But  owing  to 
the  presence  of  emphysema,  the  varying  state  of  distension  of  the  stomach 
and  intestine,  the  resistance  and  thickness  of  the  abdominal  walls,  the 
presence  of  ascitic  fluid,  the  stretching  of  the  hepatic  ligaments,  and  tight- 
lacing,  it  is  often  impossible  during  life  to  accurately  estimate  the  size  of 
the  liver,  and  still  less  its  weight,  for  its  specific  gravity  varies  according 
to  the  amount  of  fat  in  it.  As  a  rule,  the  organ  is  neither  painful  nor  tender, 
but  it  may  be  if  there  is  a  little  local  peritonitis  over  it. 

The  patient  often  has  the  aspect  of  a  drinker ;  his  nose  is  red,  the  venules 
on  his  face  are  dilated,  and  his  skin  is  of  a  muddy  tint.  He  complains  of  loss 
of  appetite,  a  nasty  taste  in  his  mouth,  nausea  and  sickness,  especially  in  the 
morning.  The  tongue  is  furred,  the  bowels  are  mostly  constipated,  but  there 
may  be  attacks  of  diarrhoea.  There  is  much  flatulence ;  often,  too,  he  is 
somewhat  wasted.  Many  of  these  symptoms  are  no  doubt  directly  due 
to  the  effect  of  the  alcohol  on  the  gastro-intestinal  mucous  membrane,  but 
some  may  in  part  be  the  result  of  portal  congestion,  which  very  frequently 
causes  piles  and  hseniatemesis.  The  bleeding  may  be  very  severe  and  the 
hsematemesis  may  be  fatal.  Melsena  may  be  present,  even  when  the  patient 
does  not  suffer  from  hasmatemesis  or  piles ;  and  I  have  seen  the  whole  of  the 
stomach  and  intestines  of  that  slaty  colour  which  is  so  suggestive  of  old 
blood  extravasation  in  their  walls. 

Ascites  is  a  common  symptom ;  it  is  more  often  associated  with  a  small 
liver  than  a  large,  probably  therefore  pressure  on  the  portal  venules  in  the 
liver  has  something  to  do  with  it.  But  it  is  not  due  to  this  alone.  Dr. 
Starling  and  I  performed  some  experiments  on  dogs,  and  we  found  that 
the  portal  vein  could  be  firmly  ligatured  without  any  ascites,  and  that  it  was 
much  easier  to  produce  ascites  by  damage  to  the  peritoneum  than  by  portal 
ligature ;  and  in  cases  of  malignant  disease  about  the  transverse  fissure  of 
the  liver,  there  may  be  no  ascites,  even  when  the  portal  vein  appears  com- 


DISEASES  OE  THE  LIVER.  777 

pressed.  On  the  other  hand,  as  has  already  been  mentioned,  chronic 
peritonitis  is  often  seen  in  association  with  cirrhosis ;  and  as  I  have  for 
some  time  past  been  accustomed  to  teach  that  this  bears  an  important 
part  in  the  production  of  the  ascites,  I  am  very  pleased  to  see  that  Auscher, 
in  his  recently  published  article,  says  that  peritoneal  lesions  are  an  undoubted 
cause  of  ascites  in  cirrhosis  of  the  liver.  The  supervention  of  ascites  augurs 
ill.  Out  of  twenty-four  cases  of  cirrhosis  with  ascites  which  I  collected,  in 
ten,  in  which  the  fluid  was  never  enough  to  call  for  tapping,  the  average 
duration  of  life  after  the  patient  first  noticed  the  abdomen  to  be  enlarging 
was  two  months;  and  among  the  fourteen  who  needed  tapping  it  was  also  two 
months ;  and  in  only  two  cases  was  life  prolonged  beyond  three  months. 

Indeed,  the  onset  of  ascites  usually  means  that  the  end  is  near,- 
from  which  it  follows  that  the  patient  hardly  ever  lives  long  after  the 
abdomen  is  tapped  ;  so  true  is  this,  that  if  the  abdomen  is  tapped  a  second 
time,  the  case  is  almost  certainly  not  one  of  uncomplicated  cirrhosis,  most 
probably  the  patient  has  chronic  peritonitis.  The  fatal  cases  which  die 
soon  after  tapping  show  the  rate  at  which  the  fluid  may  be  poured  out, 
for  I  have  known  the  abdomen,  when  the  patient  died,  to  contain  6  pints, 
although  he  was  tapped  five  days  before.  The  mere  paracentesis  is  not  the 
cause  of  the  fatal  result,  for  the  abdomen  may  be  tapped  even  hundreds  of 
times  in  other  conditions  without  any  evil  results.  The  fact  that  soon 
after  the  onset  of  ascites  very  many  patients  die — apparently  from  some 
auto-intoxication — suggests  that,  although  the  pressure  on  the  portal  vein 
and  the  state  of  the  peritoneum  are  partly  responsible  for  the  ascites,  yet 
it  may  in  part  be  due  to  some  poison  acting  upon  the  peritoneum  as  a 
lymphagogue.  The  ascitic  fluid  is  of  a  pale  straw  colour,  of  a  specific 
gravity  of  1010  to  1016  ;  it  contains  albumin  and  a  trace  of  salts,  but  no 
blood.  The  feet  are  often  swollen,  especially  about  the  ankles,  and  this 
is  usually  set  down  to  pressure  of  either  the  enlarged  liver  or  the  ascitic 
fluid  on  the  inferior  vena  cava;  but  this  is  not  always  the  cause,  for 
oedema  of  the  feet  may  be  present  when  the  liver  is  not  very  large,  when 
there  is  little  or  no  fluid  in  the  abdomen,  and  when  no  enlargement  of  the 
superficial  abdominal  veins  can  be  noticed.  Further,  patients  often  say 
that  they  noticed  the  swelling  of  the  feet  at  the  same  time  as,  or  before, 
the  abdominal  distension.  Probably  it  should,  like  the  ascites,  be  regarded 
as  evidence  that  there  is  general  poisoning.  The  superficial  veins  of  the 
abdomen  are  enlarged,  if  the  venous  communication  at  the  umbilicus  is 
well  marked.     Dyspnoea  may  be  noticed,  if  the  ascites  is  extreme. 

Jaundice  is  rarely  deep.  It  is  commoner  when  the  liver  is  large 
than  when  it  is  small,  and,  as  the  pressure  on  the  bile  ducts  is  less  when 
the  organ  is  large,  probably  we  ought  to  regard  the  jaundice  as  chiefly  due 
to  pigment  destruction  in  the  blood,  especially  as  there  is  never  any 
evidence,  such  as  dilatation  of  minute  ducts,  that  the  biliary  channels  were 
compressed.  It  is,  as  a  rule,  a  bad  sign,  but  cases  are  on  record  in  which 
it  has  persisted  for  years.  It  appears  that  little  bile  is  secreted,  for  the 
gall  bladder  is  commonly  empty,  and  the  motions,  although  not  so  white  as 
when  the  bile  duct  is  completely  obstructed,  may  be  rather  pale.  A  slow 
pulse,  and  other  signs  commonly  associated  with  jaundice,  are  very  rare. 

Urine  is  high-coloured,  rather  scanty,  and  it  contains  much  urobilin 
and  lithates ;  if  jaundice  is  present,  there  may  be  some  bile.  Often  there  is 
a  little  albumin,  but  the  same  persons  who  are  liable  to  cirrhosis  are  those 
in  whom  we  should  expect  to  meet  with  a  granular  kidney ;  and  if  the 
ascites  is  extreme,  the  albuminuria  may  be  due  to  pressure  on  the  renal 


778  ALIMENTARY  SYSTEM. 

veins.  When  the  liver  is  enlarged,  the  quantity  of  urea  excreted  may  be 
greater  than  normal ;  in  the  atrophic  cases  it  is  diminished,  but  the  total 
amount  of  ammoniacal  salts  excreted  is  said  by  many  observers  to  be 
increased.  The  spleen  may  be  enlarged  and  easily  felt.  This  is  most 
frequent  when  the  liver  is  enlarged,  and  is  probably  due  to  obstructed 
portal  flow.  Later  on  the  spleen  becomes  small  and  hard.  The  tempera- 
ture is  usually  normal,  but  it  may  be  about  100°  or  101°  in  the  evening 
even  if  no  complications  are  present.  Hsematemesis  and  melaena  have 
already  been  mentioned ;  epistaxis  and  a  mild  degree  of  purpura  may  also 
be  seen.  The  number  of  reel  corpuscles  and  the  quantity  of  hsemoglobin 
are  below  normal. 

The  onset  of  nervous  symptoms  renders  the  outlook  very  grave, 
and  if  they  are  well  marked  the  patient  usually  dies  in  a  few  days  after 
their  onset.  Coma  is  the  most  frequent,  but  he  may  have  convulsions,  and 
be  noisy,  delirious,  and  so  difficult  to  manage  that  it  is  necessary  to  place 
him  in  a  strong  room.  These  symptoms  are  almost  certainly  the  result  of 
auto-intoxication,  but  the  poison  causing  them  has  not  yet  been  isolated ; 
it  is  not  bile  pigment,  for  although  the  patients  who  show  these  symptoms 
are  often  jaundiced,  yet  they  bear  no  relationship  to  the  depth  of  the 
jaundice,  which  is  usually  slight,  and  they  may  be  present  when  there  is  no 
jaundice.  Possibly  the  poison  is  derived  from  the  failure  of  the  diseased 
liver  to  form  urea,  for  we  know  that  urea  is  much  less  poisonous  than  its 
antecedents,  and  in  acute  yellow  atrophy  (which  rapidly  causes  death) 
there  is  a  failure  to  form  urea.  Then,  too,  carbamate  of  ammonia  kills  by 
nervous  symptoms  when  the  liver  is  thrown  out  of  the  circulation,  by 
directly  connecting  the  portal  vein  with  the  vena  cava,  but  not  other- 
wise, and  it  is  a  product  of  nitrogenous  metabolism,  and  is  probably 
converted  into  urea. 

Any  of  the  other  effects  of  over-indulgence  in  alcohol,  such  as  peripheral 
neuritis,  may  be  coincident  with  cirrhosis,  but  often  the  whole  brunt  falls 
upon  the  liver.  Alcoholic  subjects  are  particularly  prone  to  phthisis,  often 
they  show  a  considerable  degree  of  atheroma,  and  granular  kidneys  and 
gout  may  be  present.  They  often  have  oedema  of  the  bases  of  their  lungs, 
and  pleural  effusion,  usually  right-sided,  is  by  no  means  rare. 

Prognosis. — The  chief  points  about  this  have  been  indicated.  If  the 
symptoms  are  slight,  the  patient  may,  with  care,  live  a  long  time.  Ascites 
and  nerve  symptoms  are  especially  bad,  but  I  have  known  cases,  in  which 
a  considerable  amount  of  fluid  was  present,  lose  all  symptoms  under 
treatment.  The  commonest  cause  of  death  is  auto-intoxication,  but 
hasmatemesis,  melsena,  and  tuberculosis,  especially  of  the  lungs  and 
peritoneum,  are  not  infrequent. 

Treatment. — It  is,  of  course,  essential  that  the  patient  should  give 
up  alcoholic  drinks.  His  diet  should  be  very  simple ;  indeed,  some  authors 
advise  milk,  but  this  will  probably  lead  to  distaste  for  it,  so  that  fish  or 
white  meat,  bread  and  butter,  toast,  plain  vegetables,  and  farinaceous 
puddings  should  form  the  chief  articles  of  food.  It  is  usually  necessary, 
either  on  account  of  the  constipation  or  the  piles,  to  order  an  aperient  to 
be  taken  two  or  three  times  a  week,  and  these  patients  do  very  well  on  some 
sulphate  of  soda  or  magnesia  water,  as  iEsculap,  Friedrichshall,  or  Pullna,  on 
rising  in  the  morning,  and  a  pill,  containing  a  little  calomel,  ipecacuanha, 
or  euonymin,  in  the  evening.  A  mixture  containing  some  mix  vomica 
and  dilute  nitrohydrochloric  acid  is  of  service  in  restoring  the  flagging 
appetite.     Three  weeks  at  Carlsbad  frequently  does  much  good.     If  ascites 


DISEASES  OF  THE  LIVER. 


779 


is  present,  I  know  of  no  drug  better  than  copaiba  resina ;  it  acts  as  a 
diuretic,  and,  as  I  have  often  seen,  a  large  amount  of  fluid  may  disappear 
entirely  under  its  use.  Fifteen  gr.  of  copaiba  resina,  suspended  with 
some  compound  tragacanth  powder,  and  flavoured  with  some  spirits  of 
chloroform,  taken  four  times  a  day,  form  a  suitable  dose.  Paracentesis 
should  only  be  done  when  the  dyspnoea  it  causes  is  serious.  The  mere 
removal  of  the  fluid  is  of  no  benefit  to  any  of  the  other  symptoms.  Lately 
the  omentum  has  been  stitched  to  the  abdominal  wall,  in  order  to  help  the 
formation  of  anastomosis  between  the  general  and  portal  venous  systems, 
but  we  have  not  yet  sufficient  experience  of  this  operation.  I  know  of 
one  case  in  which  the  patient  was  in  no  way  benefited  by  it. 

Hypertrophic  Cirrhosis. 

In  France  it  is  believed  that  there  is  a  distinct  disease,  not  specially 
related  to  alcohol,  and  in  which  the  liver  is  enlarged,  ascites  rare,  jaundice 
common,  and  splenic  enlargement  frequent.  The  liver  is  always  very 
much  enlarged  and  hard,  but  not  hobnailed ;  the  jaundice  is  well  marked 
and  lasting ;  slight  pyrexia  is  common ;  the  urine  contains  bile,  no  albumin, 
no  excess  of  lithates,  and  a  diminished  quantity  of  urea.  The  pulse  is 
not  slowed,  there  is  marked  leucocytosis.  The  patient  is  liable  to  crises 
in  which  there  is  hepatic  pain,  and  all  the  symptoms  become  worse,  but 
the  disease  often  lasts  some  years.  It  occurs  at  a  younger  age  than 
ordinary  cirrhosis,  and  is  commoner  in  men  than  women.  A  special  form 
is  described  in  children,  in  whom  the  spleen  may  reach  to  the  pelvis,  and 
the  patients  may  be  observed  to  have  some  enlargement  of  the  fingers  and 
toes.  Many  observers,  however,  do  not  draw  any  distinction  between 
hypertrophic  cirrhosis  and  ordinary  cirrhosis;  they  urge  that  the  intermediate 
cases  are  very  common,  that  many  patients  wuth  hypertrophic  cirrhosis 
have  taken  alcohol,  and  that  in  genuine  alcoholic  cirrhosis  the  liver  is 
often  enlarged,  and  that  the  so-called  hypertrophic  cirrhosis  may  be  the 
early  stage  of  a  cirrhosis  that  will  later  contract  up.  The  chief  of  those 
who  regard  hypertrophic  cirrhosis,  or  "La  cirrhose  hypertrophique  avec 
ictere  chronique,"  or  "La  cirrhose  de  Hanot"  (who  gave  a  very  full 
description  of  it),  as  a  separate  disease,  belong  to  the  French  school. 
They  regard  its  cause  as  unknown,  and  point  out  that  many  of  the  patients 
have  not  taken  alcohol  to  excess,  that  in  many  points  (character  of  liver, 
frequent  persistent  jaundice,  enlarged  spleen,  absence  of  ascites,  and  age) 
the  disease  differs  from  ordinary  cirrhosis.  Moreover,  they  believe  that 
this  disease  corresponds  to  the  cirrhosis  that  may  be  induced  by  ligature 
of  the  bile  ducts,  and  that  it  is  perilobular  and  intralobular,  while  ordinary 
cirrhosis  is  a  venous  and  not  a  bile  duct  cirrhosis,  and  it  is  multilobular 
and  extralobular.  For  my  own  part,  I  do  not  think  that  in  London  the 
distinction  between  the  two  forms  is  very  marked,  but  I  have  seen  a  case 
which  appeared  to  be  an  example  of  the  special  variety  which  occurs  in 
children. 

Malarial  Cirrhosis. 

Persons  who  have  been  in  the  tropics,  and  who  have  had  frequent  attacks 
of  ague,  often  have  an  enlarged  liver,  which  remains  large  for  many  years 
after  their  removal  from  the  district  infested  with  ague.  I  have  seen  the 
organ  reach  down  to  the  umbilicus ;  it  feels  hard,  and  its  surface  is  uniform. 
The  spleen,  too,  is  much  increased  in  size.     Although  these  patients  may 


7  80  ALIMENTAR  Y  S  YSTEM. 

be  a  little  jaundiced,  generally  they  only  show  the  pale,  sallow  tint  so 
common  in  those  who  have  had  ague.  When  the  more  usual  signs  of 
cirrhosis  are  present,  it  is  usually  difficult  to  be  sure  that  alcohol  may  not 
have  been  at  least  a  partial  cause  of  the  cirrhosis.  The  increase  of  fibrous 
tissue  is  seen  chiefly  in  the  portal  canals,  and  often  there  is  much  brown 
pigmentation. 

Saturnine  Cieehosis. 

A  few  cases  have  been  put  on  record,  in  which  lead  was  thought  to 
induce  atrophic  cirrhosis ;  and  we  must  remember  that  lead  will  cause 
cirrhosis  of  the  kidney,  and  that  it  is  very  largely  stored  in  the  liver.  If, 
however,  saturnine  hepatic  cirrhosis  exists,  it  is  excessively  rare. 

Othee  Forms  of  Cieehosis. 

Dyspeptic  cirrhosis  has  been  described,  and,  no  doubt,  excess  of  food 
will  lead  to  congestion  of  the  liver  ;  and  it  is  conceivable  that  this  might  go 
on  to  cirrhosis,  but  the  excess  of  food  is  so  frequently  associated  with  over- 
indulgence in  alcohol,  that  it  is  impossible  to  separate  the  two  conditions, 
and  for  the  same  reason  it  is  difficult  to  be  sure  if  there  is  such  a  disease  as 
gouty  cirrhosis.  A  diabetic  cirrhosis,  too,  has  been  described,  but  probably 
on  insufficient  grounds.  The  long-standing  congestion  of  heart  disease, 
although  it  increases  the  fibrous  tissue  of  the  liver,  does  not  lead  to  any- 
thing which  ought  to  be  confounded,  during  life  or  after  death,  with 
alcoholic  cirrhosis. 

An  increase  in  the  fibrous  tissue  of  the  liver  occurs  in  animals,  when 
the  bile  ducts  are  ligatured;  and  some  cases  have  been  described  as 
calculus  cirrhosis,  in  which  it  has  been  thought  that  obstruction  from 
a  gallstone  may  have  been  the  cause  of  the  cirrhosis,  but  when  we 
remember  that  this  form  of  cirrhosis  is  admittedly  very  rare,  although 
gallstones  are  common,  it  becomes  by  no  means  certain  that  we  have,  in 
medicine,  anything  to  correspond  to  experimental  biliary  cirrhosis. 

A  tuberculous  and  a  syphilitic  cirrhosis  have  been  described,  but  these 
ought  not,  either  during  life  or  after  death,  to  be  confounded  with  alcoholic 
cirrhosis. 

Much  confusion  has  been  caused  by  using  the  term  cirrhosis  to  express 
the  slight  increase  of  leucocytes  and  vascular  dilatation  sometimes  seen  in 
the  liver  after  specific  fevers,  e.g.  smallpox.  These  changes  are  not  visible 
to  the  naked  eye,  and  give  rise  to  none  of  the  symptoms  of  cirrhosis. 

I  trust  that  I  have  now  made  it  clear  that,  although,  to  the  confusion 
of  the  reader,  many  forms  of  cirrhosis  besides  that  which  we  in  England 
commonly  see,  have  been  described,  they  none  of  them  produce  the 
symptoms  or  the  alteration  in  the  liver  which  constitute  the  disease  to 
which  we  in  England  commonly  give  the  name,  cirrhosis  of  the  liver. 


NEW  FOEMATIONS  IN  THE  LIVEE. 

Malignant  Disease  of  the  Liver. 

This  may  be  either  cancerous  or  sarcomatous,  and  either  form  of  growth 
may  be  either  primary  or  secondary.  Secondary  cancer  is  so  much  the 
commoner  that  it  will  be  better  to  describe  it  first. 


DISEASES  OF  THE  LIVER.  78 1 

Secondary  Cancer  of  the  Liver. 

This  is  a  common  disease.  Thus  at  Guy's  Hospital,  during  the  years 
1888—1893,  both  inclusive,  at  least  fifty-three  patients  were  considered 
during  life  to  be  suffering  from  secondary  cancer  of  the  liver,  and  during 
the  same  period  there  were  fifteen  cases  of  hepatic  syphilis,  twelve  of 
abscess,  twelve  of  hydatid,  and  seven  of  sarcoma  of  the  liver.  But  it  is 
really  commoner,  because  often  small  secondary  deposits  are  unsuspected 
during  life;  for,  during  the  same  period,  126  examples  of  secondary  car- 
cinomatous deposits  in  the  liver  were  met  with  out  of  4200  post-mortem 
examinations,  and  50  per  cent,  of  all  persons  in  whom,  at  death,  malignant 
disease  of  any  organ  is  found,  have  secondary  deposits  in  the  liver. 

Etiology. — The  primary  seat  is  usually  found  in  the  periphery  of 
the  portal  system,  but  it  may  be  in  any  organ  which  can  be  affected  with 
primary  cancer.  The  stomach  is  the  seat  in  more  than  a  quarter  of  all 
the  cases.  The  gall  bladder,  especially  when  it  has  been  irritated  by  gall- 
stones, the  pancreas,  especially  its  head,  and  the  rectum,  are  all  common 
primary  seats.  The  greater  frequency  of  cancer  of  the  pelvic  organs  and 
breasts  of  women  explains  the  fact ;  the  proportion  of  males  to  females 
who  have  cancer  in  the  liver,  is  3  to  4. 

Morbid  anatomy. — If  the  patient  die  soon  after  the  infection  of 
the  liver,  only  a  few  small  scattered  nodules  are  seen ;  but  as  the  primary 
seat  is  usually  at  the  periphery  of  the  portal  vein,  the  liver  often  becomes 
affected  early,  and  therefore,  at  death,  large  masses  of  growth  are  found  in 
it,  and  it  is  very  heavy ;  it  may  weigh  as  much  as  20  lbs.  The  masses 
are  scattered  very  irregularly  throughout  it,  but  it  is  rare  to  find  any 
inside,  unless  they  are  visible  on  the  surface.  They  may  be  microscopic  in 
size,  or  they  may  be  as  large  as  a  fcetal  head,  and  in  a  marked  case  the 
liver  has  large  bosses  all  over  it.  The  nodules  are  at  first  globular,  but 
from  irregular  growth  and  because  those  which  are  contiguous  coalesce, 
they  soon  become  of  all  shapes  and  sizes.  On  section,  these  sharply 
defined  masses  stand  out  in  strong  contrast  against  the  liver  substance, 
which  may  be  altered  in  colour  by  bile  staining,  haemorrhage,  or  fatty 
degeneration,  and  which  is  gradually  destroyed  by  the  growth.  The 
nodules  vary  somewhat  in  colour  and  consistency,  for  they  reproduce 
exactly  the  characters  of  the  primary  disease.  They  are  supplied  with 
blood  by  branches  of  the  hepatic  artery,  which  run  along  their  fibrous 
septa.  After  a  time  their  centre  degenerates,  softens,  and  is  absorbed; 
and  the  fibrous  tissue  contracts,  so  that  if  a  nodule  is  on  the  surface  of  the 
liver,  it  becomes  umbilicated.  The  degeneration  may  lead  to  a  collection 
of  fluid  in  the  centre  of  the  growth,  or  a  vessel  may  be  laid  open,  and  then 
considerable  hemorrhage  takes  place. 

The  growth  may  appear  to  spread  to  the  gall  bladder  and  stomach,  but 
in  such  a  case  these  organs  are  nearly  always  the  primary  seat,  and  the 
disease  has  spread  from  them  to  the  liver.  As  already  mentioned,  the 
glands  on  the  transverse  fissure  are  very  frequently  enlarged,  the  cancer 
often  spreads  along  the  obliterated  umbilical  vein,  and  a  nodule  may  be 
felt  at  the  umbilicus ;  the  diaphragm  and  parietal  peritoneum,  too,  are  often 
implicated,  especially  where  they  are  in  contact  with  the  liver.  If  the 
common  duct  is  compressed,  all  the  ducts  and  the  gall  bladder  are  very 
dilated,  but  if  the  cystic  duct  is  compressed,  the  gall  bladder  is  usually 
contracted,  and  contains  only  a  little  mucus.  It  is  rare  for  the  growth  to 
spread  to  the  suprarenal  capsule,  duodenum,  or  colon. 


7  8  2  ALIMENT AR  Y  S  YSTEM. 

Symptoms. — If  the  case  is  one  in  which,  during  life,  the  diagnosis 
of  cancer  of  the  liver  can  be  made,  it  is  usually,  both  by  percus- 
sion and  tactile  examination,  discovered  to  be  enlarged.  It  may  reach 
below  the  umbilicus,  up  to  the  fifth  rib  in  the  midaxillary  line,  and  out 
as  far  as  the  spleen.  It  moves  up  and  down  with  respiration ;  this  move- 
ment may  be  visible,  and  the  lower  ribs  may  be  bulged  outwards.  The 
edge  and  surface  are  hard ;  and  if  carcinomatous  nodules  are  felt,  the  organ 
is  irregular  and  knobby,  and  the  nodules  may  be  even  made  out  to  be 
umbilicated,  and  this  is  diagnostic  of  cancer.  Occasionally  a  rub,  due 
either  to  local  peritonitis  or  the  friction  of  a  parietal  against  a  hepatic 
nodule,  may  be  heard.  The  cancer  may  grow  so  fast,  that  an  increase  in  the 
hepatic  enlargement  can  be  made  out  in  the  course  of  a  week ;  if  an  increase 
can  be  detected  within  a  day,  it  indicates  hsemorrhage  into  the  growth.  The 
umbilicus  may  be  the  seat  of  a  carcinomatous  deposit,  and  then  it  is  enlarged 
and  hard.  Pain  and  tenderness  over  the  liver  are  often  met  with,  but  not 
infrequently  they  are  absent ;  pain  in  the  right  shoulder  is  very  character- 
istic.    If  the  liver  is  hard,  the  sense  of  dragging  may  be  very  distressing. 

About  half  the  patients  suffering  from  carcinoma  of  the  liver  are 
jaundiced,  and  this  is  due  to  implication  of  the  glands  in  the  transverse 
fissure  of  the  liver,  which,  being  enlarged,  press  upon  the  common  duct. 
By  far  the  most  frequent  cause  of  long-standing  jaundice  is  carcinoma  of 
the  liver ;  in  fact,  it  is  almost  the  only  cause  in  elderly  people.  The 
jaundice  gradually  becomes  deeper  and  darker,  and  at  last  it  is  a  deep  olive 
hue.  The  gall  bladder  is  often  distended,  and  all  the  symptoms  described 
under  the  heading  of  jaundice,  as  due  to  the  presence  of  bile  in  the  blood, 
are  often  seen,  and  then  the  patient  usually  becomes  more  and  more 
drowsy,  with,  in  rare  cases,  an  occasional  convulsion;  the  coma  slowly 
deepens,  and  often,  for  several  days  before  the  end,  it  would  be  difficult  for 
a  superficial  observer  to  say  if  the  patient  is  alive  or  dead. 

Ascites  is  rather  less  frequent  than  jaundice,  and  the  two  are  associated 
in  about  20  per  cent,  of  all  cases  of  cancer  of  the  liver,  diagnosed  as 
such  during  life.  The  ascitic  fluid  is  clear,  often  bile  stained,  and  it  may 
contain  blood.  The  pressure  of  the  enlarged  glands  in  the  transverse 
fissure  is,  no  doubt,  in  part  a  cause  for  the  collection  of  fluid  in  the  abdo- 
men, but  it  is  doubtful  whether  it  is  the  sole  cause ;  for  the  size  of  the 
glands  bears  little  relation  to  the  amount  of  ascitic  fluid,  and  the  portal 
vein  can  be  ligatured  in  dogs,  and  yet  no  ascites  follows.  On  the  other 
hand,  in  cancer  of  the  liver,  some  part  of  the  peritoneum  is  usually  affected 
by  growth,  so  it  may  well  be  that  the  fluid  is  due  more  to  a  cancerous  peri- 
tonitis than  to  pressure  on  the  portal  vein. 

A  very  large  liver  may  hamper  the  movements  of  the  right  side  of  the 
chest,  and  lead  to  the  collection  of  fluid  in  the  right  pleural  cavity,  or  to 
cedema  of  the  right  lung ;  it  may  interfere  with  the  action  of  the  heart,  and 
it  may  press  on  the  inferior  vena  cava  and  cause  cedema  of  the  feet,  enlarge- 
ment of  the  superficial  abdominal  veins,  and  albuminuria.  The  urine  often 
contains  bile,  and  an  excess  of  lithates.  The  spleen  is  not  often  enlarged. 
Thrombosis  of  the  internal  saphena  vein  is  not  uncommon,  and  there  may  be 
slight  pyrexia. 

Diagnosis. — Carcinoma  of  the  liver  is  difficult  to  diagnose  with 
certainty,  if  no  primary  seat  of  growth  can  be  detected,  and  if  no  enlarge- 
ment of  the  liver  can  be  made  out ;  but  should  the  primary  seat  be  discovered, 
carcinoma  of  the  liver  may  from  the  jaundice,  etc.,  be  diagnosed,  even  if  the 
organ  is  not  enlarged.     But  the  difficulty  usually  is  to  determine  whether 


DISEASES  OF  THE  LIVER.  783 

a  patient  with  a  large  liver,  but  in  whom  the  primary  seat  of  the  growth  is 
not  obvious,  is  or  is  not  suffering  from  carcinoma  of  the  liver.  We  have 
first  of  all  to  bear  in  mind  the  many  fallacies  connected  with  an  estima- 
tion of  enlargement  of  the  liver.  Having  decided  that  the  organ  is 
enlarged,  we  next  have  to  think  of  all  the  causes  of  enlargement  of  the 
liver.  These  are  passive  venous  congestion,  passive  portal  congestion,  the 
active  congestion  of  hot  countries,  malaria,  yellow  fever,  leukaemia,  Hodg- 
kin's  disease,  pernicious  anaemia,  diabetes,  fatty  liver,  hydatid,  tropical 
abscess,  the  single  large  abscess  met  with  in  those  who  have  never  been 
abroad,  suppurating  hydatid,  actinomycosis,  tuberculous  abscess,  obstruction 
of  the  common  bile  duct,  lardaceous  disease,  hypertrophic  cirrhosis,  con- 
genital syphilis,  and  acquired  syphilis. 

The  majority  of  these  diseases  never  present  any  difficulty ;  but  it  is 
not  uncommon  for  cirrhosis,  with  an  enlarged  liver,  or  syphilis,  to  cause 
hesitation,  and  in  rare  cases  hydatid  and  obstruction  of  the  common  bile 
duct  give  rise  to  error. 

In  cirrhosis  the  nodules  are  never  larger  than  a  small  cherry,  and 
therefore  the  hepatic  enlargement  is  more  uniform  ;  they  are  never  umbili- 
cated,  neither  they  nor  the  whole  liver  alter  in  size  in  a  few  days,  and  pain 
and  tenderness  are  not  prominent  symptoms.  The  jaundice  is  never  as 
deep  nor  as  green  as  it  commonly  is  in  growth,  the  spleen  is  commonly 
enlarged ;  but  the  gall  bladder  is  rarely  distended,  and  the  stools  are  not 
completely  clay-coloured.  A  patient  with  cirrhosis  and  an  enlarged  liver 
usually  dies  sooner,  after  the  onset  of  jaundice  and  ascites,  than  does  the 
sufferer  from  cancer  of  the  liver. 

The  liver  in  congenital  syphilis  may  closely  resemble  growth,  but  the 
age  of  the  patient  will  prevent  any  mistake.  Reference  to  the  effects  of 
acquired  syphilis  on  the  liver  will  show  that  a  mistake  might  well  occur  if 
attention  were  directed  only  to  the  physical  condition  of  the  liver;  but 
jaundice,  ascites,  and  clay-coloured  stools  are  almost  conclusive  evidence  of 
growth.  Then,  too,  rapid  enlargement  of  the  organ  points  to  growth ;  but 
in  syphilis,  especially  if  iodide  of  potassium  be  given,  it  may  become 
smaller.  Pain  and  tenderness  usually  indicate  growth,  although  the  local 
perihepatitis  which  is  sometimes  associated  with  syphilis  may  cause  pain. 
Of  course  attention  must  be  paid  to  the  history  and  general  symptoms. 

The  main  points  of  distinction  between  cancer  of  the  liver  and  chronic 
blocking  of  the  bile  duct  by  gallstones,  or  by  surrounding  inflammation, 
are  that  in  these  conditions  the  patient  does  not  look  as  though  he  were 
suffering  from  cancer ;  the  hepatic  enlargement  is  uniform,  never  so  great 
as  it  often  is  in  cancer,  and  the  jaundice  does  not  become  dark  green. 

Treatment. — If  the  diagnosis  is  correct,  the  patient  must  die  before 
many  months,  and  often  death  takes  place  sooner.  Treatment  can  only 
be  palliative.  Morphine  should  be  used  freely,  if  pain  or  pruritus  are  severe. 
It  is  possible  that  in  some  cases  in  which  the  gall  bladder  is  enlarged,  the 
patient  may  be  somewhat  relieved  by  forming  a  connection  between  this 
structure  and  the  intestine ;  but  it  is  obvious  that  suitable  cases  must  be 
very  rare.  Mayo  Eobson  has  successfully  excised  a  nodule  of  growth 
from  the  liver,  but  this  is  hardly  ever  feasible. 

Primary  Carcinoma  of  the  Liver. 

The  proportion  of  undoubted  primary  to  secondary  carcinoma  of  the 
liver  is  about  one  to  twenty-five.     Early  writers  thought  primary  cancer  of 


784  ALIMENTARY  SYSTEM. 

the  liver  much  commoner,  out  that  is  because  they  sometimes  overlooked 
the  primary  seat,  aud  also  because  they  were  unaware  that  it  was  often  in 
the  gall  bladder. 

Morbid  anatomy. — There  are  three  forms  of  primary  cancer  of  the 
liver.  In  the  most  common  the  new  growth  is  deposited  in  nodules,  and 
the  whole  liver  exactly  resembles  the  organ  which  is  the  seat  of  secondary 
deposits.  In  another  class  of  case,  the  growth  consists  of  one  large  tumour 
of  the  liver.  A  very  good  instance  of  this  is  recorded  by  Bright  in  his 
monograph  on  abdominal  tumours.  In  the  third  variety  the  cancer  cells 
are  uniformly  diffused  through  the  liver,  and  there  is  a  great  increase  of 
fibrous  tissue  in  all  directions.  This  often  contracts,  so  that,  although  at 
first  the  liver  is  increased  in  size,  it  gradually  becomes  smaller. 

Symptoms. — Primary  carcinoma  of  the  liver  is  a  disease  of  adult 
life  and  generally  of  old  age.  Unlike  secondary  cancer,  it  is  rather 
commoner  in  men  than  women.  In  no  respect  does  physical  examination 
of  the  liver  reveal  any  difference  from  secondary  cancer  of  it.  Jaundice  may 
be  absent  all  through  the  illness ;  if  present,  it  usually  comes  on  late,  and  we 
never  meet  with  the  long  lasting  dark  staining  which  is  so  common  when 
the  organ  is  affected  secondarily  ;  this  is  probably  because  the  disease  is,  as 
a  rule,  rapidly  fatal.  In  about  a  third  of  the  cases,  ascites  may  be  detected 
during  life,  and  slight  pyrexia  is  rather  more  common  than  in  the  secondary 
form.  The  patients  are  often  wasted,  sometimes  they  vomit,  frequently 
they  are  constipated,  but  the  stools  are  never  clay-coloured.  The  urine 
may  contain  a  trace  of  bile  and  even  a  little  albumin. 

Diagnosis. — This  should  be  made  very  cautiously,  and  is  usually 
incorrect,  for  the  case  which  is  supposed  to  be  one  of  primary  carcinoma  of 
the  liver  commonly  turns  out  to  be  one  of  secondary  disease,  in  which  the 
primary  focus  has  been  overlooked.  The  chief  points  to  which  attention 
should  be  paid  are  that,  in  the  primary  form  the  disease  is  much  more 
rapid,  the  jaundice  is  not  deep,  and  the  motions  are  less  pale. 

Prognosis. — I  have  analysed  a  collection  of  cases  of  primary  car- 
cinoma of  the  liver,  and  the  remarkable  fact  comes  out  that  no  case  lived 
more  than  four  months  after  the  first  symptom  appeared,  and  that  the 
average  duration  was  only  twelve  weeks. 

Primary  Carcinoma  of  the  Gall  Bladder. 

This  is  not  nearly  so  rare  as  was  formerly  supposed.  Most  authorities 
agree  that  often  it  owes  its  origin  to  gall  stones,  which  are  present  in  95 
per  cent,  of  all  the  cases,  and  this  explains  the  fact  that  it  is  four  times  as 
common  in  women  as  in  men.  Secondary  deposits  in  the  liver  and  the 
portal  glands  are  very  common,  and  therefore  the  symptoms  are  much  the 
same  as  those  of  secondary  carcinoma  of  the  liver,  except  that  in  68  per 
cent,  of  the  cases  a  definite  tumour  can  be  felt  in  the  region  of  the  gall 
bladder,  and  frequently  there  is  a  history  of  gallstone  colic.  The  growth 
often  spreads  directly  to  the  liver,  stomach,  and  colon. 

Primary  Carcinoma  of  the  Bile  Ducts. 

This  is  a  rare  form  of  growth,  it  is  nearly  always  a  cylindrical-celled 
carcinoma ;  and  when  it  occurs  in  the  liver,  it  is,  until  a  histological  ex- 
amination is  made,  usually  confounded  with  primary  carcinoma  of  the 
organ.     When  it  takes  place  in  the  ducts  outside  the  organ,  the  ducts  be- 


DISEASES  OF  THE  LIVER.  785 

hind  it  and  the  gall  bladder  become  very  distended.  It  is  about  equally 
common  in  men  and  women.  The  chief  symptoms  are  deep  jaundice, 
pain,  uniform  enlargement  of  the  liver,  which  usually  contains  but  few 
secondary  nodules.  These  are  just  the  cases  of  cancer  in  which  chole- 
cystenterostomy  is  most  likely  to  relieve  the  distressing  symptoms  due  to 
the  circulation  of  bile  in  the  blood,  and  therefore  to  make  the  patient's  end 
less  distressing. 

Sarcoma  of  the  Livee. 

This  may  be  either  primary  or  secondary.  The  primary  form  is  excess- 
ively rare,  and  cannot  be  distinguished  during  life  from  primary  carcinoma, 
and  even  after  death  it  may  be  difficult  to  decide.  Secondary  sarcomata 
reproduce  exactly  the  form  of  the  original  growth  ;  they  are  rarely  diagnosed, 
for  the  patient  usually  dies  before  they  give  rise  to  any  symptoms. 

Pigment  Tumours  of  the  Liver, 

These  may  be  carcinomata  or  sarcomata,  either  primary  or  secondary. 
They  only  differ  from  the  growths'  already  described  in  being  coloured 
black,  and  therefore  melanotic  growths  of  the  liver  can  only  be  diagnosed 
during  life,  when  the  primary  growth  is  known  to  be  melanotic.  It  is  not 
uncommon  in  such  cases  to  find  only  some  of  the  hepatic  tumours  pig- 
mented. 

Angioma. 

This  occurs  with  comparative  frequency,  and  forms  a  small  ruddy  body, 
varying  in  size  from  that  of  a  filbert  to  a  walnut.  It  consists  of  dilated 
vessels,  and  is  a  subject  of  almost  purely  pathological  interest. 


SECONDARY  AFFECTIONS  OF  THE  LIVEE. 

Passive  Hyperemia. 

When  the  flow  of  blood  through  these  organs  is  impeded,  the  increased 
backward  venous  pressure  is  often  felt  very  severely  in  the  liver,  which 
becomes  uniformly  enlarged — it  may  reach  the  umbilicus — and  tender; 
if  the  stretching  of  it  has  been  rapid,  the  hepatic  pain  is  very  severe. 
The  patient  may  be  slightly  jaundiced.;  he  sits  upright  so  as  to  take 
the  weight  of  the  enlarged  liver  off  the  heart  and  lungs ;  and  in  extreme 
cases  of  cardiac  disease,  venous  expansile  pulsation  may  be  appreciated  in 
the  liver,  if  it  is  held  back  and  front  between  the  hands,  care  being  taken 
that  the  pulsation  felt  is  not  that  directly  transmitted  from  the  aorta  or 
heart.  When  this  backward  congestion  has  lasted  some  time,  the  liver  is 
seen  after  death  to  be  like  a  nutmeg,  because  the  distended  hepatic  vein 
shows  up  very  dark  in  the  centre  of  the  lobule,  the  liver  cells  atrophy,  those 
towards  the  centre  of  the  lobule  become  dark  and  bile-stained,  while  those 
at  the  periphery  are  pale  and  fatty.  The  organ  is  usually  hard,  and  there 
may  be  some  increase  of  fibrous  tissue,  but  this  is  never  sufficient  for  the 
condition  to  be  mistaken  for  the  disease  already  described  as  cirrhosis.  If 
the  congestion  is  long  continued,  there  may  be  so  much  atrophy  of  liver  cells 
and  such  dilatation  of  veins  that  there  are  shrunken  patches  containing 
cavernous  tissue ;  and  if  these  are  near  the  surface,  little  clumps  of  dilated 
venules  project  from  the  free  surface  of  the  liver,  which  may  weigh  less 
vol.  1. — 50 


786  ALIMENTARY  S  YSTEM. 

than  normal,  and  is  then  said  to  be  in  a  condition  of  racemose  atrophy. 
The  pain  of  this  form  of  congestion  of  the  liver  is  often  much  relieved  by 
leeches  applied  over  it  and  a  dose  of  calomel. 

Fatty  Degeneration. 

Some  amount  of  fat  is  found  in  the  livers  of  persons  who  have 
enjoyed  perfect  health,  and  a  considerable  amount  is  often  seen  in 
cirrhosis,  but  often  a  great  excess  of  fat  is  the  only  abnormal  feature  of  a 
liver.  The  organ  is  then  soft  and  flabby,  the  edge  is  rounded,  the  cut 
surface  is  more  yellow  than  normal,  the  liver  substance  breaks  down  easily 
under  the  finger,  and  occasionally  it  will  float  on  water.  Histologically,  it 
can  easily  be  seen  that  the  liver  cells  are  loaded  with  fat,  and  in  the  early 
stages  those  at  the  periphery  of  the  lobule  are  most  affected.  During  life 
the  uniformly  enlarged  liver  may  often  be  felt  to  have  a  smooth  rounded 
edge  and  a  soft  feel.  It  is  neither  painful  nor  tender,  and  we  do  not  know 
of  any  symptoms  which  can  be  ascribed  to  fatty  degeneration  of  the  liver. 
The  chief  causes  for  a  fatty  liver  are  alcoholic  excess  and  phthisis,  or 
indeed  any  long-standing  wasting  disease.  Very  often  a  general  over- 
indulgence is  operative.  We  often  see  the  liver  of  confirmed  drunkards 
free  from  cirrhosis,  but  very  fatty ;  but  we  are  quite  ignorant  why  alcohol 
sometimes  leads  to  cirrhosis  and  sometimes  to  a  fatty  liver.  Phosphorus 
causes  extreme  fatty  degeneration  of  the  liver. 

Waxy  Degeneeation. 

In  the  liver,  as  elsewhere,  the  deposition  of  lardaceous  material 
takes  place  first  in  the  walls  of  the  minute  arteries,  later  it  spreads 
to  the  liver  cells;  consequently,  in  the  earlier  stages  of  the  process,  it 
is  seen  in  the  middle  of  the  lobule,  but  later  most  of  the  cells  are  affected. 
The  weight  of  the  organ  is  much  increased,  it  may  reach  14  lb. ;  it  is 
smooth,  uniformly  enlarged,  hard,  and  shows  very  well  the  anatomical 
depressions  and  surfaces.  It  cuts  like  bacon,  the  surface  is  dry ;  a 
thin  section  is  translucent,  and  shows  the  individual  lobules  very  well. 
During  life  it  is  easy  to  feel,  and  may  reach  down  well  below  the  umbilicus ; 
there  is  no  pain  or  tenderness  over  it,  unless  there  is  some  coincident 
perihepatitis;  and  a  lardaceous  liver  never  causes  jaundice  or  ascites, 
but  we  can  usually  find  evidence  of  lardaceous  disease  of  the  spleen, 
kidney,  or  intestines.  Long-standing  suppuration,  which  in  the  medical 
wards  is  usually  pulmonary,  and  due  to  phthisis,  and  syphilis  are  the  only 
known  causes  of  lardaceous  disease,  but  a  few  cases  are  occasionally  seen 
in  which  no  cause  can  be  discovered.  Once  I  have  seen  it  due  to  con- 
genital syphilis,  but  this  is  very  rare.  The  diagnosis  may  be  very  difficult 
when  lardaceous  disease  accompanies  cirrhosis  or  hepatic  syphilis,  for  the 
liver  is  then  no  longer  smooth. 

Syphilis. 

If  acquired  syphilis  affects  the  liver,  it  produces  such  character- 
istic appearances,  that,  if  they  are  seen  in  the  post-mortem  room, 
they  render  it  absolutely  certain  that  the  patient  has  had  syphilis. 
The  changes  are  of  two  kinds,  gummatous  and  fibrous.  Many  gummata, 
even  fifty,  may  be  deposited  throughout  the  liver,  and  they  often  project 
on  its  surface,  and  are  always   sharply  localised.     The  early  stages   are 


DISEASES  OF  THE  LIVER.  787 

rarely  seen ;  usually  we  meet  with  a  yellowish  gummatous  mass.  In 
quite  exceptional  cases  this  liquefies,  and  it  may  then  burst,  still  more 
rarely  it  calcifies.  Each  gumma  is  surrounded  by  a  zone  of  new-formed 
fibrous  tissue,  which  sends  wide  fibrous  branching  bands  radiating  in 
different  directions  through  the  liver ;  but  the  hepatic  substance  between 
the  bands  is  healthy  and  possibly  hypertrophied,  to  compensate  for  the 
destruction  of  liver  tissue.  If  the  gumma  was  originally  very  small,  or 
has  become  so  from  absorption,  we  see  several  branching  bands  radiating 
from  a  centre,  the  gummatous  origin  of  which  is  not  obvious,  and  indeed 
it  is  said  that  these  fibrous  radii  may  form  apart  from  gummata.  In  time 
the  fibrous  tissue  contracts,  and  a  depressed  fibrous  patch  on  the  surface  of 
the  liver,  and  from  which  bands  radiate  into  the  organ,  is  very  typical  of 
syphilis.  These  depressions,  those  caused  by  the  absorption  of  gummata 
and  the  projecting  gummatous  nodules,  make  the  surface  very  knotty  and 
irregular.  The  microscope  often  shows  some  diffuse  fibrous  change,  but 
usually  it  cannot  be  seen  by  the  naked  eye,  and  the  principal  bands  are  so 
wide  and  characteristic  that  it  is  easy  to  tell  a  syphilitic  liver  from  one 
affected  with  cirrhosis.     There  may  be  some  lardaceous  change. 

During  life  the  liver  may  be  felt  to  be  enlarged,  hard,  and  irregular ; 
the  size  of  some  of  the  gummatous  nodules  may  be  observed  to  diminish 
under  treatment ;  and  the  patient  may  complain  of  pain  and  tenderness  in 
the  hepatic  region,  due  to  some  patchy  perihepatitis.  Jaundice  is 
excessively  rare ;  it  may  be  caused  by  coincident  catarrh  of  the  ducts,  to 
the  pressure  of  a  gummatous  gland,  or  to  pressure  from  cicatricial  contrac- 
tion. Ascites,  too,  is  hardly  ever  seen.  Carcinoma,  cirrhosis,  and  cirrhosis 
combined  with  syphilitic  deposits  in  the  liver,  may  all  of  them  be  exceed- 
ingly difficult  to  diagnose  from  syphilis  of  the  liver,  especially  if  it  is 
lardaceous,  for  then  it  is  much  enlarged. 

Congenital  syphilis,  as  far  as  I  know,  never  produces  effects  on  the  liver 
which  are  seen  in  adult  life.  It  may  cause  exactly  the  same  results 
as  acquired  syphilis,  and  I  have  seen  them  well  marked  in  a  child  8 
years  old ;  but  it  most  often  produces  another  effect,  which  is  usually  seen 
in  children  who  are  still-born  or  die  shortly  after  birth.  The  organ  is 
then  enlarged,  stony  hard,  inelastic,  flint  grey,  and  anaemic.  A  section  is 
smooth  and  homogeneous,  and  the  outline  of  the  individual  lobules  cannot 
be  seen,  but  they  are  represented  by  whitish  spots.  The  alteration  consists 
in  a  great  hyperplasia  of  the  young  connective  tissue,  and  is  most  marked 
in  the  neighbourhood  of  the  portal  vein,  the  walls  of  which  may  become  so 
thick  that  a  bristle  cannot  pass  down  it ;  these  changes  vary  much  in 
intensity  in  different  cases  and  in  different  parts  of  the  liver  in  the  same 
case. 

Actinomycosis. 

The  ray  fungus  may  grow  in  the  liver,  and  sometimes  this  may  be 
the  only  organ  affected.  The  effects  produced  are  in  all  their  stages  very 
like  those  caused  by  slow  tuberculous  lesions.  First,  there  is  a  small 
granulation  tumour ;  this  grows  till  it  may  be  as  big  as  a  fist ;  the 
connective  tissue  around  it  proliferates,  while  the  growth  degenerates 
in  the  centre,  where  it  finally  breaks  down  and  discharges  pus.  When 
these  growths  occurred  in  the  liver,  they  were  always  described  by  the 
older  writers  as  tuberculous,  and  indeed  they  can  often  only  be  distinguished 
either  by  noticing  the  very  bright  yellow,  glistening,  little  masses  of  ray 
fungus,  each  smaller  than  a  pinhead,  which  may  be  observed  in  the  pus  or 


788  ALIMENTARY  S  YSTEM. 

by  searching  with  the  microscope  for  the  fungus ;  but  the  fact  that  the 
abscess  cavity  is  much  trabeculated,  and  there  is  but  little  caseation,  may 
at  the  first  glance  suggest  actinomycosis  rather  than  tubercle.  During 
life  the  patient  would  complain  of  hepatic  pain  and  tenderness,  and  we 
should  observe  symptoms  of  chronic  suppuration,  with  perhaps  evidence 
of  local  swelling  in  the  liver,  and  if  the  pus  were  discharged  we  should 
find  the  ray  fungus  in  it. 

Tuberculosis. 

It  is  common  at  a  post-mortem  examination  to  see  small  grey  miliary 
tubercles  scattered  on  the  surface  and  substance  of  the  liver,  and  one  or 
two  cases  are  on  record  in  which  jaundice  has  been  associated  with 
acute  miliary  tuberculosis  of  the  liver.  Many  French  authors  have 
given  an  account  of  cirrhosis  following  these  depositions,  and  have  also 
described  a  tuberculous  cirrhosis  occurring  without  the  deposition  of  tubercle 
in  the  liver,  but  I  cannot  help  thinking  that  the  French  school  have  much 
exaggerated  the  importance  of  tuberculous  cirrhosis.  Very  rarely  the  liver 
may  contain  several  small  caseous  tuberculous  abscesses,  and  in  still  more 
exceptional  cases  large  tuberculous  caseous  abscesses  occur  in  it.  I  have 
seen  one  such  case,  and  one  has  been  successfully  operated  on  by  Mayo 
Eobson.  It  is  only  when  these  large  abscesses  form  that  tubercle  of  the 
liver  becomes  of  clinical  interest ;  and  an  abscess  should  never  be  stated  to 
be  tuberculous  till  the  bacillus  has  been  found,  for  abscesses  due  to 
actinomycosis  are  much  like  those  due  to  tubercle.  In  advanced  cases  of 
phthisis  the  liver  is  often  lardaceous  or  fatty,  and  it  may  be  swollen  from 
obstructed  pulmonary  circulation. 


HYDATID   OF   THE  LIVEE. 

Etiology  and  pathology. — This  disease  of  the  liver  is  due  to  the 
swallowing  the  ova  of  the  T.  echinococcus.  This  tape-worm  is  rather  less' 
than  a  quarter  of  an  inch  long,  and  when  fully  developed  consists  of 
four  segments ;  the  most  anterior  (the  head)  is  small,  and  has  four 
sucking  discs  and  a  rostellum  of  from  thirty  to  forty  hooklets ;  the  last 
three  segments  are  called  proglottides ;  the  second  and  third  are  quite 
small,  but  the  posterior  is  larger  than  the  other  three  together,  and 
alone  contains  sexual  organs.  This  tape-worm  inhabits  the  alimentary 
canal  of  the  dog,  and  its  ova  are  discharged  in  the  fasces ;  hence 
hydatid  of  the  liver  is  commonest  in  Iceland,  where  dogs  live  in  the 
same  huts  as  the  inhabitants.  It  is  often  seen  in  Australia,  where  dogs 
are  used  for  herding  sheep,  and  it  is  by  no  means  rare  in  England.  In 
Iceland  it  is  more  common  in  women,  as  they  clean  the  dogs ;  in  Australia 
it  is  met  with  chiefly  in  men,  as  there  they  are  brought  most  into  contact  with 
dogs.  In  the  last  seven  years,  there  have  been  sixteen  cases  in  Guy's 
Hospital.  No  age  is  exempt.  When  the  ova  have  been  swallowed  by  man, 
their  shell  is  dissolved;  the  contained  embryo  or  scolex,  which  has  six 
little  hooks  arranged  in  two  rows,  bores  its  way  into  the  wall  of  the 
stomach  or  intestines,  and  from  there  may  be  carried  to  any  part  of  the 
body,  but  most  frequently  it  is  taken  by  the  portal  vein  to  the  liver.  Of 
1862  cases  quoted  by  Osier,  the  parasites  existed  in  the  liver  in  953,  in 
the  intestinal  canal  in  163,  in  the  lungs  or  pleura  in  153,  in  the  kidneys, 
bladder,  or  genitals  in  186,  in  the  brain  and  spinal  cord  in  127,  in  the 


DISEASES  OF  THE  LIVER.  789 

bones  in  61,  in  the  heart  and  blood  vessels  in  61,  in  other  organs  in  158. 
It  becomes  stationary  in  some  part  of  this  organ,  loses  its  hooks,  and 
gradually  becomes  a  cyst  containing  clear  fluid.  The  wall  of  this  cyst 
thickens,  and  consists  of  pearly  white  translucent  layers.  The  outer,  the 
thicker,  is  laminated,  and,  when  torn,  curls  back  in  the  reverse  way  to  its 
natural  curve ;  the  inner  layer  is  granular,  and  is  said  to  contain  muscular 
fibres.  The  hepatic  tissue  around  a  cyst  is  compressed  and  becomes 
converted  into  a  thin  layer  of  fibrous  tissue,  but  the  hydatid  cyst  is  not  in 
continuity  with  this,  and  can  always  be  shelled  out  from  it.  On  the  inner 
surface  of  the  cyst  a  number  of  minute  projections  form ;  these,  under  the 
microscope,  are  found  to  be  scolices  or  heads,  exactly  like  the  first  joint  of 
the  T.  echinococcus,  and  they  usually  undergo  cystic  degeneration,  and 
form  cysts  exactly  like  the  original  cyst,  which  has  therefore  a  number  of 
daughter  cysts  in  its  interior;  these  become  detached  from  the  parent 
wall  and  lie  free  in  the  parent  cyst.  The  process  may  be  repeated,  and 
grand-daughter  cysts  form  in  the  daughter  cysts,  and  again  repeated,  till 
there  is  a  number  of  cysts  one  within  the  other.  But  there  comes  a  stage 
when  the  cysts  remain  attached  to  the  wall  of  the  parent  cyst  by  a  pedicle ; 
they  are  then  called  brood  capsules,  because  a  number  of  fully-developed 
heads  or  scolices,  each  complete  with  suckers  and  hooklets,  grow  from  the 
interior  surface  of  the  cyst  and  project  into  its  interior.  These  are  usually 
arranged  so  that  the  suckers  and  hooks  are  turned  inwards.  The  fluid  of 
these  cysts  is  clear,  limpid,  of  a  low  specific  gravity — imder  1010 ;  it 
contains  chloride  of  sodium  and  occasionally  a  trace  of  sugar,  and  of 
succinate  of  ammonium  but  no  albumin,  a  fact  by  which  it  is  easily  known 
from  pleural  and  peritoneal  effusion.  A  few  scolices,  several  hooklets,  and 
even  fragments  of  laminated  membrane,  may  often  be  seen  in  it  on  micro- 
scopical examination.  A  hydatid  of  the  liver  may  become  very  large ;  it 
may  be  almost  as  large  as  the  liver  itself ;  the  hepatic  tissue  being  reduced 
to  a  thin  layer  all  over  it ;  or  it  may  form  a  tumour  as  large  as  a  man's 
head,  projecting  from  the  liver.  It  may  contain  several  pints  of  fluid  and 
hundreds  of  daughter  and  grand-daughter  cysts,  but  it  is  rare  in  man  for  a 
liver  to  contain  more  than  one  hydatid  tumour.  Not  infrequently  hydatids 
die,  the  fluid  is  then  absorbed,  the  parent  cyst  contracts,  and  is  ultimately 
filled  with  much  bile  stained  putty-like  matter,  mixed  with  calcareous 
salts  and  glistening  cholesterin  crystals,  a  number  of  empty  cysts  com- 
pressed together,  and  many  hooklets,  which,  being  calcareous,  have  escaped 
disintegration.  Death  of  the  cyst  usually  takes  place  while  it  is  still 
rather  small,  and  so  dead  hydatids  are  often  found  in  the  post-mortem 
room,  when  there  was  nothing  during  life  to  indicate  their  presence.  The 
fibrous  surrounding  of  dead  hydatids  becomes  very  dense  and  often 
calcareous.  Sometimes  the  original  cyst  produces  no  daughter  cysts ;  it  is 
then  called  an  acephalocyst  hydatid. 

Very  rarely  the  daughter  cysts  bud  off  externally  instead  of  internally, 
and  as  this  process  goes  on  indefinitely  the  liver  may  become  riddled 
with  hydatid  cysts,  and  they  may  even  extend  to  neighbouring  organs.  I 
have  known  a  hydatid  originating  in  the  liver  to  grow  in  this  way  into 
the  pleura,  which  became  full,  and  was  found  to  contain  many  hundreds 
of  these  cysts.  In  this  case,  failure  to  boil  the  fluid  extracted  with  an 
exploring  needle,  led  to  an  erroneous  diagnosis  of  simple  pleuritic 
effusion. 

Multilocular  hydatid,  which  is  excessively  rare,  was  always  regarded 
as  a  cystic  form  of  malignant  disease,  till  Virchow  in  1855  first  showed 


790  ALIMENTARY  SYSTEM. 

its  true  nature.  It  forms  a  solid  globular  mass  in  the  liver ;  it  may 
be  6  in.  in  diameter.  It  can  be  shelled  out  of  the  organ.  On  section, 
it  contains  numerous  smooth-walled  cavities,  about  the  size  of  small  peas  or 
smaller,  having  in  them  gelatinous  fluid,  which  has  in  it  many  hydatid 
membranes  compressed  together ;  and  usually  some  scolices  can  be  found, 
if  looked  for  carefully.  A  series  of  sections  show  that  these  cavities 
communicate  with  each  other.  Multilobular  hydatids  are  always  found  to 
be  softening  in  their  centre.  Their  mode  of  development  is  not  thoroughly 
understood.  It  has  been  suggested  that  in  this  form  of  hydatid  the 
parasite  occupies  the  interior  of  the  lymphatics. 

Symptoms. — These  may  almost  be  inferred  from  the  above  de- 
scription of  the  cause  of  the  disease.  A  hydatid  of  the.  liver,  if  it  does 
nob  suppurate  or  rupture,  can  hardly  be  diagnosed  unless  it  produces  an 
enlargement  of  the  organ.  This  may  be  detected  either  by  palpation  or 
percussion ;  it  is  confined  to  one  part  of  the  liver,  most  often  the  right  lobe, 
and  is  rounded  and  smooth,  but  neither  painful  nor  tender.  If  it  begins 
near  the  edge  of  the  liver,  and  grows  very  large,  it  may  require  considerable 
care  to  demonstrate  that  it  is  connected  with  the  liver  at  all ;  on  the  other 
hand,  if  it  starts  in  the  interior,  a  large  hydatid  may  produce  little  altera- 
tion in  the  shape  of  the  liver.  Even  if  the  tumour  is  accessible,  the  feel  of 
it  may  vary  much,  sometimes  distinct  fluctuation  may  be  obtained,  at  others 
the  cyst  is  so  tense  that  it  feels  quite  hard.  Much  attention  has  been  directed 
to  the  "  hydatid  thrill,"  but  it  is  often  absent,  and  may  be  occasionally  felt 
in  any  tense  cyst  whatever  its  origin.  To  obtain  it,  a  finger  of  the  left 
hand  is  placed  on  the  cyst  and  struck  with  one  of  the  fingers  of  the  right 
hand,  the  left  finger  may  then  feel  a  distinct  thrill  under  it.  Ascites, 
enlargement  of  the  spleen,  oedema  of  the  lower  extremities,  albuminuria 
and  jaundice,  are  all  accidental  and  very  rare  symptoms ;  they  form  no  part 
of  the  clinical  picture  of  hydatid  of  the  liver,  and  they  indicate  that  the 
cyst  presses  on  the  portal  vein,  the  inferior  cava,  or  the  bile  duct,  as  the 
case  may  be.  A  hydatid  cyst  has  been  known  to  rupture  into  the  bile 
ducts  and  cause  jaundice,  into  the  gall  bladder  and  produce  biliary  colic, 
or  into  the  portal  vein  or  the  inferior  cava.  The  latter  accident  causes 
instant  death.  If  an  exploring  needle  which  has  been  thrust  into  the 
hepatic  tumour  draws  fluid  which  has  the  characters  of  hydatid  fluid,  the 
diagnosis  is  certain.  As  already  mentioned,  a  hydatid  may  die,  but  if  left 
alone  it  is  always  liable  to  rupture,  either  spontaneously  or  subsequent  to 
a  blow.  This  rupture  may  take  place,  not  only  in  the  direction  just 
mentioned,  but  also  into  the  pleura  or  lung,  into  the  peritoneal  cavity,  into 
the  stomach,  into  the  intestine,  into  the  urinary  passages,  into  the  peri- 
cardium, or  externally.  Eupture  into  the  pleural  cavity  or  lung  is  the 
commonest,  and  rupture  in  any  direction  is  usually  either  fatal  immediately 
or  later  on,  as  a  result  of  the  suppuration  induced.  Hydatid  cysts  may 
also,  if  left  alone,  kill  by  pressure  upon  important  organs,  or  by  exhaus- 
tion ;  not  infrequently  they  suppurate  (see  "  Abscess  of  the  Liver  ") ;  and 
lastly,  death  may  be  due  to  implication  of  other  organs  by  the  rare  form 
of  hydatid  which  buds  externally.  It  must  not  be  forgotten  that  some- 
times several  organs  may  be  simultaneously  affected  with  the  common 
forms. 

Diagnosis. — A  hydatid  at  the  upper  part  of  the  right  lobe  of  the 
liver  may,  if  it  suppurate,  easily  be  confounded  with  an  abscess  between 
the  liver  and  diaphragm.  A  non-suppurating  hydatid  in  this  position  has 
.often  been  mistaken  for  pleuritic  effusion,  but  the  upper  limits  of   the 


DISEASES  OF  THE  LIVER.  791 

fluid  in  pleuritic  effusion  is  horizontal,  while  that  of  the  hydatid  is  dome- 
shaped.  The  diagnosis  from  encysted  pleuritic  effusion  may  be  very 
difficult,  but  nearly  always  a  supposed  right-sided  encysted  basal  pleurisy 
turns  out  to  be  a  hydatid  cyst  growing  from  the  liver.  A  distended 
gall  bladder  is  distinguished  from  a  hydatid  cyst  by  its  position, 
its  shape,  the  history  of  colic,  and  by  the  fact  that  jaundice  is  usually 
present.  But  the  distinction  is  often  far  from  easy,  and  I  have  seen  the 
mistake  made  when  every  care  was  taken  to  prevent  it.  It  should  not  be 
forgotten  that  a  hydatid  cyst  may,  by  rupturing  into  the  gall  bladder, 
cause  symptoms  very  like  those  of  gallstones.  A  deep-seated  hydatid 
may  be  difficult  to  distinguish  from  a  lardaceous  liver,  especially  if  this  has 
in  it  syphilitic  fibrous  tissue  and  gummata.  Fagge  points  out  that  such  livers 
do  not  move  freely  on  respiration,  owing  to  adhesions,  and  there  is  often 
some  pain  and  tenderness,  but  the  liver  with  a  hydatid  in  it  moves  freely, 
and  is  neither  painful  nor  tender.  The  diagnosis  of  hydatid  from  cancer 
may  generally  be  made  from  a  consideration  of  the  whole  of  the  symptoms  of 
the  case.  A  renal  cyst  may  easily  simulate  a  hydatid  tumour  of  the  liver, 
but  to  avoid  a  mistake  attention  must  be  paid  to  the  origin  of  the  cyst  and 
the  direction  of  its  growth,  to  its  movement  with  respiration,  and  to  the 
presence  of  the  colon  in  front  of  it.  Unfortunately,  it  may  be  so  large  that 
its  origin  cannot  be  determined ;  a  renal  cyst  may,  owing  to  the  attachment 
of  the  kidney  to  the  liver,  move  on  respiration,  and  the  colon  may  be 
empty.  I  have  seen  a  phantom  tumour  of  the  rectus  so  closely  resemble 
a  hydatid  of  the  liver  that  the  diagnosis  could  not  be  made  until 
chloroform  had  been  administered.  In  all  these  cases  of  difficulty  the 
examination  of  the  fluid  withdrawn  by  an  exploring  needle  will  settle 
the  diagnosis. 

Prognosis. — As  old  dead  hydatid  cysts  are  found  post-mortem,  it  is 
clear  that  sometimes  the  disease  undergoes  a  spontaneous  cure.  We  have 
no  knowledge  of  the  cause  of  this,  nor  do  we  know  how  long  a  hydatid  can 
live,  although  we  do  know  'that  their  growth  is  very  slow.  Consider- 
ing the  risks  from  rupture  and  suppuration,  it  is  generally  allowed  that 
if  a  hydatid  of  the  liver  has  been  diagnosed,  surgical  interference  is 
necessary. 

Treatment. — Simple  aspiration  which  does  not  require  an  anaesthetic 
may  certainly  sometimes  kill  the  parasite,  and  lead  to  a  complete  cure 
without  any  re-collection  of  the  fluid,  but  often  it  does  re-collect,  sometimes 
the  dead  hydatids  induce  suppuration,  and  it  is  usually  very  difficult  to 
say  whether  or  not  the  case  is  cured.  The  technique  of  free  incision  into 
the  cyst  has  been  improved  so  much  of  late  years,  that  most  surgeons 
prefer  to  expose  the  liver  over  the  cyst,  stitch  it  to  the  abdominal  wall,  pack 
carefully  around  it,  then  evacuate  the  cyst,  and  leave  in  a  wide  drainage 
tube.  As  the  escape  of  a  little  hydatid  fluid  into  the  peritoneum  does  no 
harm,  it  is  usual  to  do  all  the  operation  at  one  sitting ;  but  if  there  is  no 
urgency,  the  opening  may  be  deferred  after  the  stitching  of  the  cyst  to  the 
abdominal  wall,  until  adhesions  have  formed.  As  far  as  possible,  all  the 
cysts  and  membrane  should  be  removed  at  the  time  of  operation ;  if,  how- 
ever, all  cannot  be  taken  away,  those  that  are  left  will  usually  be  dis- 
charged in  a  few  days.  The  seat  of  operation  will  be  determined  by 
the  position  of  the  hydatid.  Those  at  the  back  of  the  liver,  which  cannot 
be  reached  except  through  the  pleura,  may  be  evacuated  through  the 
pleura,  but  they  require  considerable  skill  and  judgment  in  their  surgical 
treatment. 


792  ALIMENTARY  SYSTEM. 

In  very  rare  cases,  erythema  or  urticaria,  either  of  which  may  be  very 
extensive,  has  appeared  on  the  body  after  tapping  a  hydatid  cyst,  and 
generally  the  rash  is  accompanied  by  a  high  temperature  and  abdominal 
pain.  Sometimes,  too,  the  patient  may,  after  the  tapping,  be  seized  with 
faintness,  dyspnoea,  and  vomiting ;  he  becomes  cold,  the  pulse  becomes  very 
weak,  and  he  may  die.  Both  these  effects  are  extremely  uncommon.-  ISTo 
explanation  of  them  is  forthcoming.  Some  experiments  of  Eoy's  appeared 
to  show  that  hydatid  fluid  is  a  respiratory  and  cardiac  depressant ;  but 
Graham  has  failed  to  confirm  this. 


OTHER   CYSTS. 

A  "hydatid  cyst  is  the  only  cyst  of  the  liver  of  any  great  clinical  im- 
portance ;  but  there  are  on  record  several  interesting  cases  in  which  cysts, 
which  are  certainly  not  hydatid,  have  been  found  in  the  liver  and  in  other 
organs  in  the  same  patient.  Pye-Smith  has  recorded  an  example,  and  I 
have  described  cases  and  given  references  to  the  subject.  These  cysts  must 
never  be  confounded  with  the  holes  in  the  liver  which  are  the  result  of 
decomposition,  which  may  make  it  look  like  a  sponge. 

Several  species  of  flukes  have  been  found  in  the  human  liver.  A  serious 
endemic  disease,  due  to  a  fluke,  exists  in  Japan ;  but  in  England  flukes  are 
only  of  post-mortem  interest.     They  may  be  found  dead  and  calcified. 


PEPJHEPATITIS. 

By  this  term  we  understand  an  inflammation  of  the  peritoneal  capsule 
of  the  liver ;  it  is  either  acute  or  chronic.  The  acute  is  merely  a  part  of 
some  acute  process,  such  as  a  hepatic  abscess  or  acute  peritonitis. 

Chronic  perihepatitis  is  either  partial  or  universal.  Instances  of  partial 
perihepatitis  are  the  local  peritonitis,  which  occurs  round  a  thickened  gall 
bladder,  and  that  seen  over  a  gumma.  Partial  perihepatitis  is  also  often 
present  on  livers  enlarged  as  a  result  of  disease  of  the  heart  or  lungs.  This 
variety  of  perihepatitis  is  of  little  clinical  interest.  Universal  perihepatitis 
is  a  condition  in  which  the  whole  capsule  of  the  liver  is  thick,  opaque,  and 
white. 

Etiology.  —  The  ■  condition  is  almost  always  associated  with  and 
a  part  of  general  simple  chronic  peritonitis.  I  took  from  the  post- 
mortem records  at  Guy's  Hospital,  quite  at  random,  forty  cases  of  peri- 
hepatitis. Eighteen  were  examples  of  partial,  twenty-two  of  com- 
plete perihepatitis.  Of  these  twenty-two,  in  two  it  was  stated  that 
there  was  no  peritonitis,  in  seventeen  there  was  peritonitis,  and  in 
the  remaining  three  there  is  no  mention  of  the  peritoneum.  In 
none  of  the  seventeen  was  the  peritonitis  due  to  tubercle  or  growth ; 
but  it  was  always  that  chronic  form  in  which  the  peritoneum  be- 
comes thick  and  opaque,  the  omentum  puckers  up  and  forms  a  thick, 
hard  mass,  and  the  mesentery  shrinks  and  drags  the  intestines  back  to  the 
spine.  The  intestines  may  be  so  matted  together  that  they  can  be  removed 
en  masse.  These  facts  prove  the  statement  just  made,  that  universal  peri- 
hepatitis is  nearly  always  part  of  a  general  simple  chronic  peritonitis.  As 
in  nineteen  out  of  the  twenty-two  cases  the  kidneys  were  granular,  we 


DISEASES  OF  THE  LIVER.  793 

must  regard  Bright's  disease  as  being  perhaps  the  most  important  cause  of 
perihepatitis ;  perhaps,  also,  syphilis  is  a  cause,  for  two  of  the  remaining 
three  cases  had  suffered  from  syphilitic  symptoms. 

The  liver  is  rarely  enlarged ;  but  if  the  lower  edge  of  it  can  be  felt,  it  is 
thick,  rounded,  and  uniform.  The  other  signs  of  chronic  peritonitis  and  of 
chronic  interstitial  nephritis  are  usually  present.  The  most  important 
sign  of  chronic  peritonitis  is  ascites,  which  requires  frequent  tapping,  be- 
cause the  fluid  re-collects  after  it  has  been  withdrawn.  Thus  I  have  known 
a  case  tapped  thirty  times ;  indeed,  chronic  peritonitis  is  by  far  the  most 
common  cause  of  ascites  that  needs  frequent  tapping.  The  puckered 
thickened  omentum  may  be  felt  as  a  hard  mass  lying  across  the  abdomen, 
just  above  the  umbilicus,  and  as  the  ascitic  fluid  collects,  the  abdomen 
quickly  becomes  dull  all  over,  because  the  intestines  are  drawn  back  by  the 
puckering  of  the  mesentery.  If  the  fluid  becomes  loculated  in  and  among 
the  coils  of  intestine,  where  it  may  be  shut  off  by  peritoneal  adhesions,  the 
case  may  be  very  difficult  to  diagnose.  The  average  age  at  death  among 
my  cases  was  47|  years.  The  youngest  was  29,  the  eldest  68.  The  pro- 
portion of  males  to  females  was  as  thirteen  to  eight. 

Morbid  anatomy. — The  white  jacket  of  the  liver,  which  often  has 
little  pits  on  it,  may  be  a  quarter  of  an  inch  thick ;  it  easily  peels  off  the 
surface  of  the  liver,  which  is  quite  smooth,  and  the  inferior  edge  of  it  may 
be  folded  up  on  to  the  anterior  surface  of  the  organ  and  fixed  in  this 
position  by  the  jacket.  The  hepatic  tissue  is,  according  to  Fagge, 
commonly  soft,  and  is  very  often  loaded  with  fat.  It  is  seldom  cirrhotic, 
but  there  is  sometimes  an  excess  of  fibrous  tissue  in  the  course  of  the  large 
portal  vessels.  The  liver  with  its  thickened  capsule  usually  weighs  be- 
tween 50  and  60  oz.,  from  which  we  may  conclude  that  the  organ  itself  is 
somewhat  atrophied.  The  thickened  capsule  does  not  exert  enough 
pressure  to  cause  jaundice,  and  the  ascites  is  to  be  ascribed  to  the  peri- 
tonitis and  not  to  pressure  on  the  portal  vein,  for  I  have  by  dissection 
proved  that  this  is  not  compressed  by  the  thickened  hepatic  capsule. 

Diagnosis. — These  cases  are  usually  confounded  with  cirrhosis ;  but 
in  perihepatitis  jaundice  is  absent,  the  signs  of  chronic  peritonitis  are 
present,  and  the  patient  usually  survives  several  tappings.  Eeference  to 
the  description  of  cirrhosis  will  show  that  this  last  fact  is  very  strong 
evidence  of  chronic  peritonitis  rather  than  ascites, 

Treatment. — The  abdomen  must  be  tapped  as  may  be,  necessary. 
No  drug  is  known  to  be  beneficial,  but  iodide  of  potassium  may  be  tried. 

W.  HALE  WHITE. 


794 


ALIMENTARY  SYSTEM. 


DISEASES   OF   THE   PANCREAS. 

In  order  to  obtain  some  information  as  to  the  relative  frequency  of  disease 
of  the  pancreas,  I  searched  the  records  of  the  post-mortem  examinations 
made  at  Guy's  Hospital  for  the  twelve  years  1883-1894  both  inclusive, 
during  which  period  almost  6000  post-mortem  examinations  were  made. 
Once  an  accessory  pancreas  was  found,  and  on  ninety-nine  occasions  (or 
in  1-6  per  cent.)  the  organ  appeared  to  the  morbid  anatomist  to  be 
diseased.     The  following  table  gives  a  summary  of  the  ninety-nine  cases  : — 


Cirrhotic,  congested,  or  hard  pancreas 
Primary  malignant  disease  of  pancreas     . 
Small  pancreas       ..... 

Secondary  deposits  of  growth  in  pancreas 
Fatty  pancreas       ..... 

Malignant  growths  of  other  organs  adherent  to  pancreas 
Pancreatic  cysts  (including  one  case  of  hydatid) 
Pancreatic  calculi  ....... 

Floor  of  ulcer  of  stomach  formed  by  pancreas 
Tubercle  of  pancreas      ...... 

Dilatation  of  pancreatic  ducts  not  due  to  growths     . 
Floor  of  ulcer  of  duodenum  formed  by  pancreas 
Ruptured  pancreas  from  cart  wheel 
Abscess  in  pancreas         ...... 

(Edema  of  pancreas  from  heart  disease    . 


20 

19 

16 

11 

8 

7 

4 

3 

3 

2 

2 

1 

1 

1 

1 


99 


CIRRHOSIS. 


When  the  pancreas  is  congested  and  hard,  the  condition  is  nearly 
always  the  result  of  long-standing  venous  pressure.  In  eleven,  or  rather 
over  half  the  cases,  this  was  due  to  disease  of  the  heart,  and  then  the 
liver  was  usually  nutmegged ;  in  a  much  smaller  number  it  appeared 
to  be  caused  by  disease  of  the  lung.  In  two  at  least  it  was  associated 
with  cirrhosis  of  the  liver,  in  one  there  was  an  enormous  ovarian 
cyst,  which  might  well  have  exercised  pressure  on  the  portal  vein,  in 
another  a  large  mass  of  portal  glands  infiltrated  with  growth  pressed 
upon  the  portal  vein.  It  is  impossible  to  classify  the  causes  more 
exactly,  for  sometimes,  as  in  cases  with  advanced  phthisis  and  cirrhosis 
of  the  liver,  it  is  difficult  to  assign  the  share  in  the  causation  of  the 
hardness  of  the  pancreas  correctly  among  those  organs,  disease  of  any 
one  of  which  might  have  been  the  cause.  The  important  fact  is  that  in 
one  out  of  every  three  hundred  post-mortem  examinations,  the  pancreas 
is  congested  and  hard  from  backward  venous  pressure.  Microscopically, 
there  is  a  great  increase  in  the  amount  of  fibrous  tissue,  usually  it  lies 
between  the  lobules,  but  it  may  extend  into  them  ;  there  is  also  consider- 
able small-celled  infiltration.  I  have  once  known  the  pancreas  to  be  so 
hard,  and  so  easily  felt  after  the  abdomen  had  been  tapped,  that  it  was 
mistaken  for  a  mass  of  malignant  disease.  In  three  cases  of  diabetes  the 
pancreas  was  especially  hard.  Riedel  has  in  very  rare  cases  noticed  a 
chronic  inflammatory  enlargement  of  the  head  of  the  pancreas  in  associa- 
tion with  gallstones,  and  no  doubt  due  to  the  irritation  of  their  passage. 


DISEASES  OF  THE  PANCREAS.  795 


ATEOPHY. 

In  thirteen  out  of  sixteen  cases  the  patient  suffered  from  diabetes, 
and  this  is  the  commonest  pancreatic  condition  found  associated  with 
diabetes.  Sometimes  the  organ  only  weighed  an  ounce.  Usually  it  was 
described  as  soft  and  flabby,  but  in  a  few  instances  it  was  hard.  In  two 
of  the  remaining  three  cases  there  was  much  abdominal  malignant  disease, 
so  that  there  may  have  been  much  interference  with  the  blood  supply  of 
the  pancreas,  and  the  third  patient  was  an  old  woman,  who  died,  shortly 
after  admission,  from  the  effects  of  a  severe  burn. 


FATTY   CHANGES. 

In  all  these  eight  cases  the  infiltration  of  the  pancreas  with  fat  was 
evident  to  the  naked  eye.  Two  of  the  patients  were  young  (7  and  16 
years  old),  and  both  had  mitral  disease  with  backward  pressure.  Six  were 
elderly,  their  average  age  being  66.  Five  of  these  were  surgical  cases. 
A  study  of  all  eight  cases  appears  to  show  that  there  are  two  groups — one 
in  which  a  fatty  pancreas  is  associated  with  backward  pressure,  and 
another,  comprising  elderly  persons,  who  are  bad  surgical  subjects,  and 
who  usually  have  evidence  of  degeneration  of  other  viscera. 


CALCULI. 

As  these  were  only  found  three  times  in  6000  post-mortem  examina- 
tions, they  are  clearly  very  rare. 

From  a  study  of  these  cases,  and  others  scattered  through  literature,  it 
appears  that  pancreatic  calculi  are  usually  composed  largely  of  carbonate 
of  lime — although  the  pancreatic  secretion  contains  none  ;  they  are  white 
in  colour ;  sometimes  rounded,  but  often  branching  coral-like  masses ;  the 
ducts  in  the  organ  are  nearly  always  dilated,  for  the  most  part  uniformly, 
but  sometimes  they  form  small  cysts  containing  a  white  mucoid  fluid. 
Very  often  the  pancreas  is  hard  and  indurated,  containing  an  excess  of 
fibrous  tissue,  apparently  as  a  result  of  the  obstruction  of  the  duct  by  the 
calculus.  Large  cysts  and  abscesses  are  very  rare.  By  far  the  greater 
number  of  the  patients  are  males  over  40  (the  three  Guy's  cases  were  all 
males,  and  their  ages  were  70,  58,  and  55).  Pancreatic  calculi  have  been 
found  in  the  fasces,  but  apart  from  this  it  is  hardly  possible  to  diagnose 
their  presence  during  life.  There  is  very  little  evidence  that  they  cause 
colic ;  some  of  the  persons  in  whom  they  have  been  found  have  had 
glycosuria.  Vomiting  has  been  present  in  some  cases,  and  it  is  stated 
that  the  fasces  may  contain  much  fat,  and  that  there  may  be  diarrhoea  with 
fatty  stools.  They  have  been  known  to  produce  jaundice  from  impaction 
in  the  duodenal  orifice. 

It  will  be  noticed  that  in  the  list  of  ninety-nine  cases,  two  are  given  of 
dilated  pancreatic  duct ;  one,  in  which  jaundice  was  present,  was  fatal,  owing 
to  an  unsuccessful  cholecystenterostomy ;  the  duodenal  orifice  was  found 
closed  by  an  old  cicatrix ;  in  the  other,  the  pancreatic  ducts  were  dilated 
without  obvious  cause.  In  one  of  the  cases  of  pancreatic  cyst  there  was 
a  small  cavity  in  the  head  which  opened  into  the  duodenum;  the  view 


796  ALIMENTARY  SYSTEM. 

taken  at  the  autopsy  was  that  a  small  abscess  in  the  pancreas  had 
ruptured  into  the  duodenum,  and  as  the  patient  died  of  hsematemesis 
and  melsena,  most  likely  in  so  doing  it  opened  a  vessel.  All  these  cases 
probably  represent  the  after  effects  of  calculi. 


MALIGNANT  DISEASE. 

Primary. 

This  is  rare,  occurring  once  in  about  every  three  hundred  autopsies.1 
The  proportion  of  males  to  females  is  two  to  one.  As  pancreatic  calculi 
are  commoner  in  men,  it  may  be  that  they  by  their  irritation  can  induce 
malignant  disease  of  the  pancreas ;  but  as  they  are  so  exceptional,  this 
cannot  be  common.  Sarcoma  is  very  rare ;  it  occurred  once  in  the 
nineteen  cases  from  Guy's ;  this  patient  was  pet.  28.  The  patients  afflicted 
with  carcinoma  were  usually  between  40  and  60.  The  youngest  was 
33,  and  the  oldest  73.  The  growth  is  nearly  always  limited  to  the  head  of 
the  gland,  it  may  be  quite  large ;  one  tumour  measured  9  in.  across, 
but  this  was  of  exceptional  size.  Scirrhus  is  much  more  common 
than  medullary  carcinoma.  It  is  probable  that  as  in  the  liver  so 
in  the  pancreas,  the  primary  seat  of  the  growth  may  occasionally  be 
in  the  ducts.  Cancerous  growths  of  the  pancreas  have  been  known 
to  undergo  colloid  degeneration.  Bright  records  cases  in  which  they 
ulcerated  into  the  duodenum ;  and  a  patient  of  mine  died  from  hasmate- 
mesis,  clue  to  an  ulceration  of  a  cancer  of  the  pancreas  into  the  stomach. 
Secondary  deposits  may  occur  almost  anywhere,  but  by  far  the  most 
common  seats  are  in  the  portal  glands  and  the  liver.  One  of  the 
nineteen  cases  I  have  collected  showed  considerable  fat  necrosis  of  the 
omentum.  It  is  very  important  to  remember  that  either  by  pressure  of 
the  enlarged  portal  glands,  or  by  the  direct  pressure  of  the  original  tumour 
in  the  head  of  the  pancreas,  the  patient  may  be  jaundiced  and  the  bile 
ducts  dilated ;  and  in  at  least  a  third  of  the  cases  the  gall  bladder  is 
considerably  distended,  and  the  liver  itself  may  be  enlarged.  The 
pancreatic  ducts,  too,  are  often  dilated.  The  most  frequent  symptom  is 
constant  severe  abdominal  pain ;  usually  the  patient  says  it  is  deep  down 
above  the  umbilicus,  but  in  one  case  it  was  referred  to  the  back.  Vomit- 
ing, which  in  most  cases  is  very  difficult  to  treat  successfully,  and  which 
bears  no  relation  to  food,  is  common.  In  about  half  the  cases  there  is 
obvious  wasting,  and  this  may  be  very  marked.  The  bowels  are  con- 
stipated, and  if  the  patient  is  jaundiced  the  stools  may  be  clay-coloured  ; 
and,  as  Bright  pointed  out  many  years  ago,  the  motions  may  contain  large 
quantities  of  fat — it  may  be  so  abundant,  that  it  forms  a  thick  scum, 
particularly  about  the  edges  of  the  vessel  containing  the  fasces.  As  an 
obstruction  of  the  common  bile  duct  is  so  frequent,  and  this  kind  of  motion 
is  so  rare,  it  is  likely,  as  taught  by  Gairdner,  that  it  is  due  to  blocking  of 
the  pancreatic  duct.  This  probably  bears  on  the  statement,  which  I  can 
confirm  from  personal  observation,  that  the  subjects  of  pancreatic  cancer 
die  sooner  and  waste  more  rapidly  than  most  sufferers  from  carcinoma. 
These  patients  are  usually  markedly  anaemic,  and  if  there  is  oedema  of  the 
ankles  it  may  be  due  to  this,  or  to  pressure  on  the  inferior  vena  cava. 

1  Mayo  Robson  has  recently  suggested  that  some  cases  of  supposed  malignant  disease  of 
the  liver  are  examples  of  chronic  pancreatitis,  and  he  has  enlarged  our  knowledge  of  this  con- 
dition. 


DISEASES  OF  THE  PANCREAS.  797 

The  tumour  may  be  so  large  that  it  can  be  seen ;  thus  the  report  of  a 
case  under  Pye-Smith  says,  there  was  a  large  globular  swelling  in  the 
right  epigastric  region  bulging  the  ribs.  This  turned  out  to  be  a 
malignant  growth  at  the  head  of  the  pancreas  as  large  as  a  foetal  head. 
If  it  cannot  be  seen,  the  tumour  may  in  many  cases  be  felt  as  a  hard 
immobile  mass,  usually  tender,  and  having  transmitted  pulsation  from  the 
aorta,  and  resonant  if  the  stomach  or  colon  in  front  of  it  contains  gas. 
The  abdominal  muscles  on  the  right  side  are  often  rigid.  The  enlarged 
liver  and  gall  bladder  may  be  easy  to  feel.  But  still  it  must  be  remem- 
bered that  often  malignant  disease  of  the  pancreas  is  suspected  because 
the  patient  has  abdominal  pain,  vomiting  and  wasting,  for  which  no 
other  cause  can  be  suggested.  Kecently,  from  these  symptoms  in  one  of 
my  patients  this  diagnosis  was  made,  although  no  growth  could  be  felt 
even  under  chloroform.  The  gall  bladder  was  not  dilated,  and  there  was 
no  jaundice.  The  diagnosis  turned  out  to  be  quite  correct,  the  pancreatic 
growth  being  confined  to  the  tail  of  the  gland. 

The  symptoms  due  to  the  spread  of  the  growth  are  not  numerous.  In 
a  case  of  my  own,  it  grew  so  much  to  the  right  that  the  calibre  of  the  duo- 
denum was  very  much  diminished,  and  no  doubt  the  patient's  constipation 
and  vomiting  were  partly  referable  to  this.  Not  long  ago,  a  patient  was 
admitted  into  the  hospital  for  intestinal  obstruction,  caused  by  a  growth  of 
the  colon.  It  was  found  that  the  primary  disease  was  in  the  head  of  the 
pancreas,  and  the  growth  in  the  colon  was  only  due  to  direct  spreading 
of  the  growth  from  the  pancreas.  In  another  instance  besides  that 
previously  mentioned,  the  stomach  was  affected  in  a  similar  way.  I  have 
seen  the  semilunar  ganglia  extensively  infiltrated  in  a  case  of  scirrhus  of 
the  pancreas. 

Little  good  is  gained  by  a  long  account  of  the  differential  diagnosis. 
Mistakes  are  most  often  avoided  by  those  who  are  most  thorough  and 
careful  in  their  examination.  I  have  known  a  patient  in  whom  a 
malignant  growth  in  the  pancreas,  which  did  not  spread  to  the  bowel, 
produced  such  extreme  constipation  that  he  was  operated  on  for  intestinal 
obstruction ;  and  in  another  patient  with  the  same  disease,  the  constancy 
of  the  pain,  the  jaundice,  the  distended  gall  bladder,  and  the  vomiting,  led 
to  an  operation  because  he  was  thought  to  be  suffering  from  an  impacted 
gallstone.  It  may  be  very  difficult  to  decide  whether  the  case  is  one  of 
carcinoma  of  the  pylorus  or  of  the  head  of  the  pancreas ;  malignant  disease 
of  the  colon  or  gall  bladder  may  give  rise  to  error,  and  primary  malignant 
disease  of  the  pancreas  may  be  overlooked  as  a  cause  for  secondary  deposits 
in  the  liver. 

All  that  can  be  done  is  to  treat  the  symptoms.  Morphine  is  very 
valuable. 

Secondary  Growths. 

Six  of  these  eleven  cases  were  carcinomata.  The  primary  growth  was 
in  the  stomach,  sigmoid  flexure,  rectum,  ovary,  peritoneum,  or  breast.  In 
two  instances  the  secondary  deposit  was  in  the  head  of  the  pancreas,  twice 
the  organ  was  generally  infiltrated,  once  the  tail  only  was  affected,  and 
once  the  tail  and  head,  the  intervening  portion  being  free.  Four  cases 
were  sarcomata,  the  primary  growth  being  in  bone  twice  and  in  the 
mediastinum  twice.  In  one  instance  the  nature  of  the  primary  growth 
is  not  stated.  It  is  clear  that  the  pancreas  is  not  a  frequent  seat  of 
secondary  deposits. 


798  ALIMENTARY  SYSTEM. 

Malignant  Adhesions. 

In  four  cases  the  primary  growth  was  in  the  pylorus,  once  in  the  lesser 
curvature  of  the  stomach,  once  in  the  colon,  and  once  it  was  sarcomatous 
in  the  abdominal  glands.  Thus  we  see  that  almost  the  only  growth  likely 
to  be  adherent  to  the  pancreas  is  one  in  the  pylorus. 


PANCEEATIC   CYSTS. 

These  are  very  rare.  Only  three  were  found  in  6000  autopsies 
at  Guy's.  One  was  an  example  of  that  curious  condition  in  which  cysts 
are  found  in  many  organs  in  the  same  patient.  In  this  case  they  were 
in  the  cerebellum,  kidney,  and  pancreas.  The  duct  of  Wrisberg  was 
neither  obstructed  nor  dilated.  The  case  is  recorded  by  Pye-Smith,  and 
references  are  given  to  the  whole  subject  by  Savage  and  myself.  Another 
was  an  instance  of  hydatid  of  the  pancreas ;  this  is  excessively  rare,  and 
I  know  of  no  means  by  which  to  diagnose  it  from  the  cysts  about  to  be 
described,  unless  some  of  the  fluid  were  examined. 

The  pancreas  is  liable  to  the  formation  of  large  cysts,  of  which  our 
third  case  was  an  instance,  the  causation  of  which  is  very  obscure.  They 
are  not  due  to  blocking  of  the  duct,  for  no  obstruction  can  be  found  ;  the 
duct  is  not  dilated ;  when  it  is  compressed  by  a  growth,  cysts  do  not  form 
in  the  pancreas  ;  and,  lastly,  when  the  bile  duct  is  compressed,  cysts  do  not 
form  in  the  liver.  It  has  been  suggested  that  these  cysts  are  due  to  injury, 
but  there  is  no  proof  of  this.  They  are  almost  equally  common  in  the  two 
sexes,  and  may  occur  at  any  age,  but  they  are  most  often  met  with  between 
20  and  40.  The  cyst  is  very  tense,  and  of  large  size ;  it  may  fill  the  abdomen, 
and  hold  many  pints  of  fluid;  one  contained  15  litres.  It  has  a  specific 
gravity  of  between  1010  and  1020,  is  alkaline,  contains  between  1  and  3 
per  cent,  albumin,  and  is  generally  turbid.  The  colour  has  varied  much 
in  different  cases,  in  most  it  has  been  either  green  or  brown ;  but  white, 
opalescent,  and  yellowish  red  fluids  have  been  described,  and  it  has  even 
been  stated  to  be  clear.  Usually  there  is  mucin  and  a  sugar -forming 
ferment  in  it ;  leucin,  tyrosin,  blood  pigment,  and  urea,  have  all  been 
found  in  some  cases.     It  may  emulsify  fats. 

A  pancreatic  cyst  could  hardly  be  diagnosed  until  it  is  felt ;  indeed,  the 
patient  often  does  not  consult  a  doctor  until  he  himself  notices  a  tumour, 
which,  if  produced  by  a  pancreatic  cyst,  is  smooth,  rounded,  and  tense.  It  is 
situated  above  the  umbilicus,  and  more  to  the  left  than  to  the  right  of  the 
middle  line ;  the  recti  are  rigid  ;  it  cannot  be  moved  about  by  the  hand ;  it 
moves  but  little  on  respiration,  and  the  edge  of  the  liver  is  unconnected  with 
it.  The  great  and  essential  point  to  determine  is  its  relation  to  the  stomach. 
This  should  be  distended  with  gas  by  giving  separately  the  two  portions 
of  a  seidlitz  powder  ;  and  then  by  percussion,  succussion,  and  palpation, 
it  will  be  easy  to  make  out  that  the  stomach  is  in  front  of  the  tumour. 
The  colon,  too,  may  be  shown  to  be  in  front  by  distending  it  with  water. 
This  is  easy,  if  the  buttocks  are  raised  on  two  or  three  pillows,  and  a 
quantity  of  water  is  run  into  the  rectum  by  means  of  a  long  indiarubber 
tube  with  a  funnel  raised  considerably  above  the  patient.  There  is  no 
reason  for  supposing  that  when  it  is  small  a  pancreatic  cyst  gives  rise  to 
any  symptoms,  but  as  it  grows  the  patient  may  complain  of  pain  because 
the   cyst   presses  or  drags  upon   surrounding   structures.      Pressure   on 


DISEASES  OF  THE  PANCREAS.  799 

the  stomach  may  cause  vomiting,  with  much  dyspepsia,  and  then 
the  patient  loses  flesh.  The  bowels  may  be  constipated.  In  several 
cases  pressure  on  the  bile  duct  has  led  to  jaundice,  varying  much  in 
intensity  in  different  cases,  because  the  precise  position  and  degree 
of  distension  of  the  cyst  vary.  There  may  be  a  little  albuminuria,  and 
if  the  destruction  of  pancreatic  tissue  is  very  great,  the  urine  may  contain 
sugar.  A  distinct  increase  in  the  size  of  a  cyst  can  often  be  noticed 
in  a  fortnight,  and  if  it  is  tapped  the  fluid  soon  collects  again.  Severe 
haemorrhage  may  take  place  into  a  pancreatic  cyst,  and  then  the  patient 
may  become  suddenly  collapsed. 

It  is  possible  that  a  peritoneal  blood  cyst  may  be  in  such  a  position  as 
to  closely  resemble  a  pancreatic  cyst,  and  it  might  be  that  a  diagnosis 
could  only  be  made  by  examining  the  fluid  removed  by  an  exploratory 
puncture.  Pancreatic  cysts  have  been  mistaken  for  ovarian  cysts,  but 
proper  care  should  prevent  this. 

When  we  remember  that  the  stomach  and  colon  are  in  front  of  these 
cysts,  it  is  clear  that  exploratory  puncture  from  the  front  is  attended 
by  danger.  Usually  exploration  is  not  necessary,  but  if  it  is,  the 
cyst  can  often  be  reached  by  a  fine  needle,  thrust  in  below  and  a  little 
behind  the  tip  of  the  twelfth  rib,  and  as  it  is  retroperitoneal,  the 
peritoneum  will  probably  not  be  wounded.  Unless  the  patient  has 
diabetes,  in  which  case  it  would  probably  be  best  to  aspirate  from  time 
to  time,  these  cysts  should  be  laid  open  and  drained  by  an  incision 
below  the  outer  part  of  the  left  twelfth  rib.  If  the  patient  has  not 
diabetes  he  generally  recovers. 


TUBEECLE. 

In  the  two  cases  mentioned  there  were  caseous  nodules  in  the  gland, 
and  both  had  peritoneal  tuberculosis.  Tubercle  of  the  pancreas  is 
excessively  rare.     Gumma  of  the  pancreas  is  known. 


ACUTE  PANCREATITIS. 

By  far  the  best  account  of  this  rare  disease  is  that  given  by  Fitz.  He 
suggests  that  it  is  usually  due  to  the  extension  of  a  gastro-intestinal 
inflammation  along  the  pancreatic  duct,  and  he  describes  three  varieties 
differing  in  their  morbid  anatomy  and  symptoms.  A  few  cases  have 
been  recorded  in  England.     I  myself  have  seen  one. 

HEMORRHAGIC   PANCREATITIS. 

This  occurs  between  the  ages  of  25  and  60,  and  is  commoner  in  men 
than  in  women.  About  half  the  patients  have  been  liable  to  colicky  attacks 
and  indigestion.  The  immediate  attack  begins  suddenly  with  pain,  generally 
very  severe,  and  most  intense  in  the  upper  part  of  the  abdomen.  Shortly 
after,  the  patient  begins  to  vomit,  and  in  most  cases  he  is  constipated.  Soon 
(usually  in  the  course  of  a  day  or  two)  he  is  extremely  collapsed,  and 
in  most  instances  he  is  dead  by  the  third  day ;  life,  nevertheless,  may  be 
continued  to  the  sixth  day,  but  the  patient  rarely  survives  the  onset  of 
the  collapse  more  than  a  few  hours.     The  abdomen  may  be  somewhat 


800  ALIMENTARY  SYSTEM. 

distended  and  resonant.  After  death  it  is  seen  that  much  blood  is 
extravasated  into  the  pancreas,  and  it  may  also  be  seen  around  the 
organ.  There  is  histological  evidence  of  acute  inflammation  of  it,  fat 
necrosis  is  seen  in  its  lobule,  and  often  too  in  the  mesentery  and 
omentum,  and  the  pancreatic  vessels  may  contain  ante-mortem  clot. 
This  disease  is  liable  to  be  confounded  with  acute  intestinal  obstruc- 
tion, but  in  pancreatitis  the  abdominal  distension  is  not  great,  definite 
intestinal  coils  are  not  seen,  the  onset  of  the  collapse  does  not 
coincide  with  the  onset  of  the  illness,  and  an  enema  may  bring  away 
fgeces.  Local  tenderness  is  a  point  in  favour  of  pancreatitis,  very  severe 
vomiting  and  a  dry  tongue  point  rather  to  obstruction.  If,  when  a 
laparotomy  has  been  performed,  under  the  impression  that  the  case  is 
one  of  intestinal  obstruction,  no  distended  coils  with  collapsed  coils 
beyond  can  be  seen,  the  pancreas  should,  if  possible,  be  inspected,  and  if 
it  is  diseased  the  wound  should  be  sewn  up,  and  the  patient  treated  with 
general  stimulants.  Osier  records  such  a  case,  in  which  the  patient  made 
a  good  recovery,  and  was  well  five  years  later.  This  disease  has  been 
confounded  with  perforative  peritonitis.  The  previous  history  (gall- 
stones, gastric  ulcer,  appendicitis,  etc.),  the  abdominal  distension,  the 
immobility  of  the  abdomen,  thoracic  breathing,  early  collapse,  and  sub- 
sequent reaction,  and  other  signs  of  peritonitis,  will  help  us.  Poisoning 
should  always  be  borne  in  mind.  Every  possible  means  should  be  adopted 
to  maintain  the  patient's  strength. 

Suppurative  Pancreatitis. 

Fitz  has  collected  twenty-one  cases.  Their  ages  vary  between  20  and  74 
Seventeen  were  males,  four  were  females.  Most  were  chronic.  In  the  acute 
cases  the  onset  is  marked  by  the  sudden  supervention  of  intense  abdominal 
pain  and  incessant  vomiting.  At  first  the  bowels  are  constipated,  later  there 
is  diarrhoea.  Slight  fever  is  noticed  about  the  third  day;  the  abdomen 
is  then  distended  and  tender,  and  hiccough  is  frequent.  The  patient 
dies  in  the  course  of  about  a  week,  and  the  pancreas  is  found  studded 
with  minute  abscesses,  many  of  which  have  burst  into  the  peritoneum, 
setting  up  acute  peritonitis.  The  chronic  cases,  which  often  drag  on 
for  months,  may  in  their  onset  exactly  resemble  these  acute  cases,  or  they 
may  throughout  behave  like  a  chronic  pyaemia;  in  the  course  of  a  few 
weeks  the  upper  part  of  the  abdomen  becomes  tender  and  rigid,  but  a 
distinct  tumour  is  very  rare.  A  circumscribed  single  abscess  of  consider- 
able size  is  usually  found.  This  may  open  into  the  stomach,  duodenum,  or 
cavity  of  the  great  omentum.  Pylephlebitis  and  abscesses  of  the  liver  may 
result,  jaundice  is  occasionally  present.  Fat  necrosis  is  rare.  The  abscess 
in  the  one  case  of  pancreatic  abscess  which  occurred  in  the  ninety-nine 
cases  of  pancreatic  disease  I  collected,  was  in  the  head  and  quite  small, 
and  as  the  duct  was  dilated  it  may  have  been  due  to  a  calculus.  The 
patient  died  of  carcinoma  of  the  colon.  Pancreatic  abscess  may  be  due  to 
septic  thrombosis. 

Gangrenous  Pancreatitis. 

This  may  be  secondary  to  perforative  inflammation  of  the  gastro- 
intestinal or  biliary  tract,  but  it  usually  results  from  hemorrhagic  pan- 
creatitis, and  is  fatal  in  a  few  weeks.     The  gangrenous  process  extends 


DISEASES  OF  THE  PANCREAS.  801 

to  the  tissues  around  the  pancreas,  produces  more  or  less  complete 
sequestration  of  it,  and  the  sequestrated  gland  may  lie  in  the  omental 
cavity  soaked  in  pus.  Both  pus  and  pancreas  may  be  discharged  into 
the  intestine,  and  at  least  two  cases  are  on  record  of  recovery  after  this 
event.  Phlebitis  of  the  splenic  vein  is  common,  and  the  patient  may 
have  diabetes.  The  symptoms  are  at  first  those  of  acute  hsemorrhagic 
peritonitis ;  later,  weakness,  slight  pyrexia,  vomiting,  diarrhoea,  abdominal 
distension,  and  fatal  symptoms  of  collapse  are  frequent.  There  may  be 
obvious  local  tenderness,  or  even  a  tangible  tumour.  If  the  disease  could 
be  diagnosed,  the  right  treatment  would  be  to  open  the  abscess  in  the  way 
recommended  for  a  pancreatic  cyst. 


HEMORRHAGE. 

It  has  already  been  mentioned  that  bleeding  may  take  place  into 
pancreatic  cysts,  but  apart  from  that  an  apparently  healthy  person  may 
be  suddenly  seized  with  symptoms  of  severe  collapse,  ending  in  a  few 
hours  in  death.  The  pancreas  and  the  subperitoneal  tissue  round  it  are 
found  infiltrated  with  blood,  which  may  even  extend  into  the  mesentery, 
the  omentum,  and  the  peritoneal  region.  No  cause  for  this  disease  is 
known.  The  rest  of  the  viscera  are  usually  healthy  ;  fat  necrosis  is  very 
rare.     In  almost  half  the  cases  there  is  intense  abdominal  pain. 


EAT  NECEOSIS. 

Contiguous  groups  of  fat  cells  in  the  pancreas  and  in  the  subperitoneal 
tissue  may  undergo  necrosis;  the  fatty  acids  unite  with  lime  salts,  the 
fat  becomes  crystalline,  and  a  number  of  opaque  white  or  yellowish, 
rather  hard  patches,  usually  varying  in  size  between  a  pin's  head  and 
a  split  pea,  and  raised  slightly  above  the  surface,  are  seen.  They  are 
liable  to  be  mistaken  for  tubercles  or  nodules  of  new  growth,  and  in 
rare  instances  have  been  as  large  as  a  hen's  egg.  These  opaque  masses 
melt  on  heating,  stain  with  osmic  acid,  and  under  the  microscope  seem  as 
it  were  set  among  normal  cells,  with  very  little  inflammatory  reaction 
around  them.  Fat  necrosis  is  far  more  common  in  the  peritoneum  than 
elsewhere ;  the  next  most  frequent  seat  is  probably  the  pancreas,  but  it  has 
been  described  in  the  subpleural,  subperi cardial,  and  subcutaneous  fat,  and 
in  the  marrow  of  bones.  In  the  peritoneum  it  is  usually  in  the  neigh- 
bourhood of  the  pancreas,  and  it  is  found  most  frequently  in  association 
with  disease  of  that  region — especially  hemorrhagic  pancreatitis.  It  has 
been  seen,  too,  in  peritonitis,  either  chronic  or  acute,  and  in  various  other 
conditions.  Often  the  pancreas  is  distinctly  stated  to  be  healthy.  Pan- 
creatic juice  can  cause  necrosis  of  fat,  but  the  origin  of  fat  necrosis  is  not 
properly  understood. 

W.  HALE  WHITE. 


VOL.  I 51 


8o2  ALIMENTARY  SYSTEM. 

DISEASES  OF  THE  PEKITONEUM. 
INTRODUCTORY. 

The  abdominal  cavity,  as  it  is  termed,  is  in  health  one  in  name  only — a  mere 
potential  cavity.  When  the  potential  becomes  actual,  disease  is  present. 
Normally  the  surfaces,  lined  by  peritoneal  serous  membrane,  are  closely 
pressed  together  throughout  their  entire  extent ;  only  a  small  quantity  of 
serous  fluid,  secreted  by  some  of  the  endothelial  lining  cells  and  reabsorbed 
by  others,  intervening.  This  serous  fluid  flows  in  a  direction  which  is 
chiefly  from  below  upwards.  The  surface  cells  over  the  greater  omentum 
apparently  possess  the  most  marked  powers  of  absorption,  although  the 
peritoneal  membrane  as  a  whole  exhibits  this  faculty  to  a  wonderful 
degree.  May  be  the  peritoneal  faculty  for  rapid  removal  of  fluids  from  its 
sac  is  not  so  surprising,  when  the  wide  expanse  of  surface  presented  by  it  is 
considered ;  its  total  superficies  almost  equalling  that  of  the  body  itself. 
Thus  the  peritoneum  is  able  not  only  to  secrete  fluids,  but  to  reabsorb 
them,  and  as  a  general  rule  the  origin  and  the  symptoms  of  peritoneal 
disease  are  closely  related  to  disturbance  of  one  or  other  of  these  functions, 
except  in  cases  of  new  growths,  malignant  and  benign,  in  which  the  causes 
are  mainly  independent  of  peritoneal  secretion  and  absorption,  although 
many  of  the  symptoms  exhibited  have  their  origin  in  disturbance  of  these 
functions.  The  causes  of  diseases  of  the  peritoneum  are  appended  in  the 
table  on  p.  821. 

Throughout  this  article  use  is  made  of  data  derived  from  the  records  of 
the  Edinburgh  Eoyal  Infirmary  for  the  nine  years  from  1891  to  the  end  of 
1899 — data  as  yet  unpublished.  In  these  statistics,  attacks  of  peritonitis 
consequent  upon  surgical  operations,  and  cases  of  pelvic  perimetritis  and 
peritonitis  in  the  gynaecological  wards,  are  ignored.  Of  72,375  patients 
treated,  10,411,  or  14-3  per  cent.,  suffered  from  some  morbid  affection  of  the 
digestive  system;  1179 — P62  per  cent,  of  the  total  cases,  and  11*3  per 
cent,  of  those  with  alimentary  disease — were  victims  of  peritoneal  disorders. 
In  Table  II.  (p.  823)  the  results  of  the  analysis  of  these  cases  are  shown  in 
terms  of  sex  and  age.     The  figures  tell  their  own  tale. 

PERITONITIS. 

Acute  Peritonitis. 

An  acute  inflammatory  condition  of  the  serous  membrane  lining  the 
peritoneal  cavity;  primary  or  secondary  in  nature;  general  or  local  in 
character. 

Etiology. — Acute  simple  peritonitis  (so-called  idiopathic  peri- 
tonitis).— This  is  an  acute  inflammation  of  the  peritoneum  occurring  apart 
from  evident  organic  lesion.  It  is  a  matter  of  grave  doubt  whether  inflam- 
matory affections  of  the  peritoneal  membrane  can  ever  develop  wholly  inde- 
pendent of  concrete  external  influences.  It  is  true  that  cases  of  acute  and 
chronic  peritonitis  often  occur  to  which  it  is  impossible  to  assign  any  direct 
cause,  or,  after  death,  to  detect  any  gross  lesion  accountable  for  them. 
The  peritoneal  membrane  possesses  a  remarkable  facility  for  the  removal 
and  neutralisation  of  toxic  bodies,  mainly  due,  in  all  probability,  to  its 
great  power  of  rapid  absorption,  and  in  a  lesser  degree,  perhaps,  to  a  certain 


DISEASES  OF  THE  PERITONEUM.  803 

bactericidal  property  which  has  been  ascribed  by  many  to  the  secretion  of 
its  lining  cells.  It  is  a  fact  worthy  of  consideration  in  relation  to 
peritoneal  diseases,  that  the  endothelial  cells  covering  the  walls  of  the  sac 
are  constantly  secreting  fluid  into  a  theoretical  cavity — a  fluid  which  is 
as  constantly  being  absorbed  again  through  the  membrane.  Both  the 
secretion  and  the  absorption  of  fluid  are  in  great  part  physiological 
processes,  dependent  for  their  normal  pursuance  upon  the  healthy  condition 
of  the  endothelial  cells  forming  the  serous  coat.  Whenever  the  normal 
activity  of  these  cells  is  altered,  their  healthy  tone  diminished,  or  their 
vitality  destroyed,  the  processes  of  secretion  and  absorption  are  modified. 
Decreased  power  of  absorption  is  of  greater  influence  in  causing  abnormal 
disturbance  than  increased  secretion  alone.  The  importance  attaching  to 
unimpeded  peritoneal  absorption  is  explained  by  the  fact  that  toxic 
substances  present  in  the  peritoneal  fluid  are  rapidly  conveyed  to  the 
under  liver,  to  be  rendered  innocuous  in  the  cells  of  that  great  defensive 
organ  of  the  body  under  normal  conditions. 

In  idiopathic  peritonitis,  chills,  traumatism  without  the  actual  wound- 
ing of  the  membrane,  constitutional  diseases  such  as  gout  and  rheumatism, 
debilitating  diseases,  chronic  kidney  disease,  profound  or  pernicious 
anaemia,  and  diabetes,  are  credited  with  a  greater  or  less  share  in  causa- 
tion. A  point  of  weight  in  this  connection  is  supplied  by  the  positive 
evidence  of  various  observers  as  to  the  permeability  of  the  intestinal 
mucous  membrane  and  its  outer  coverings,  including  the  peritoneal  coat, 
to  various  bacterial  forms  with  or  without  macroscopic  lesion ;  the 
possibility  of  invasion  of  the  sac  by  bacteria  circulating  in  the  blood; 
and  the  much  more  facile  intrusion  of  chemical  poisons,  alkaloids, 
ptomaines,  or  leucomaines,  through  its  walls.  Some  authorities  maintain 
that  bacteria  are  able  to  pass  through  the  intestinal  walls  and  reach  the 
peritoneal  cavity,  even  although  these  are  perfectly  healthy ;  while  others 
again  are  of  opinion  that  this  is  impossible  unless  there  be  some  peritoneal 
lesion  present.  Whichever  side  the  truth  lies  on,  it  is  notorious  that  local 
abscesses,  extraperitoneal,  adjacent  to,  but  having  no  direct  communication 
with  the  lumen  of,  the  bowels,  are  invariably  foetid  and  contain  organismal 
forms  which  have  undoubtedly  come  from  the  contents  of  the  gut.  In 
appendicitic  and  perityphlitic  intraperitoneal  abscesses,  with  no  perforation 
of  the  bowel,  the  pus  is  generally  swarming  with  other  forms,  in  addition 
to  those  micro-organisms  normally  found  in  suppuration. 

It  may  be  stated,  however,  as  a  general  rule,  that  the  passage  into  the 
peritoneum  of  bacteria  from  the  bowel  cannot  per  se  cause  an  attack  of 
peritonitis,  unless  they  be  present  in  excessive  numbers  (in  which  case 
some  gross  lesion  of  the  intestinal  wall  is  probably  present),  except  where 
there  is  a  hindrance  to  absorption  or  the  coincident  presence  of  an  excess 
of  irritating  and  poisonous  toxines.  The  peritoneum  is  quite  able  to  deal 
with  any  bacteria  which  may  manage  to  penetrate  the  healthy  intestinal 
coverings,  even  if  it  has  to  strictly  confine  their  action,  and,  by  building  a 
boundary  wall,  protecting  the  major  portion  of  the  sac,  permit  of  a  purely 
local  inflammation  pursuing  a  local  course.  But  should  there  be  a  loss  of 
tone  over  a  portion  of  its  visceral  substance,  accompanied,  it  may  be,  with 
reflex  disturbance  of  varied,  while  discrete,  causation,  in  the  protoplasmic 
activities  of  the  endothelial  cells,  bacteria  may  be  able  to  gain  entrance 
in  such  large  numbers,  and  the  peritoneal  membrane  be  so  much 
affected  as  to  be  unable  to  deal  with  them,  that  even  without  any  gross 
lesion  inflammation  may  be  set  up.     Especially  would  this  be  the  case  if 


8o4  ALIMENTARY  SYSTEM. 

abnormal  processes   in  the  intestinal  contents  coexisted,   from  stasis,  or 
putrefactive  fermentation  with  absorption  of  poisonous  toxines. 

To  sum  up.  Cases  of  acute  idiopathic  peritonitis  are  probably  the  result 
of  some  interference  with  the  bactericidal  power  of  the  peritoneal  sac, 
normally  exercised  against  the  bacteria  derived  from  the  bowel,  lowered 
vitality  of  the  endothelial  cells,  such  as  follows  chills  or  trauma,  and 
accompanies  constitutional  affections  and  general  debility. 

Acute  secondary  peritonitis  (acute  bacterial  peritonitis). — This  is  an 
acute  inflammation  of  the  peritoneum,  following  invasion  by,  or  extension 
of,  infective  and  irritant  matter,  either  diffuse  or  localised,  with  or  without 
suppuration. 

Acute  secondary  peritonitis  arises  by  extension  from  acute  inflam- 
matory processes  affecting  organs  or  tissues  immediately  adjacent  to 
the  peritoneal  membrane,  by  direct  contact  with  infection  after  perfora- 
tion of  the  gut,  from  intrusion  of  the  contents  of  an  abscess,  from  the 
poison  of  acute  general  diseases,  or  by  local  development  of  tubercle 
bacilli.  Those  cases  which  are  caused  by  extension  from  adjacent  in- 
flammatory foci  differ  from  idiopathic  forms,  if  the  etiological  factors 
given  above  are  accepted,  only  in  degree,  not  in  nature.  Acute  inflamma- 
tion of  the  intestinal  wall,  such  as  is  common  in  the  protean  forms  of 
intestinal  obstruction,  in  strangulation  of  a  hernia,  volvulus,  intussus- 
ception, intraperitoneal  constriction,  or  appendicitic  occlusion,  may  be 
followed  by  acute  peritonitis,  although  no  actual  rupture  of  the  gut  has 
occurred.  Whenever  perforation  of  the  gastric  or  intestinal  wall  leads  to 
entrance  of  the  contents  of  these  organs  into  the  peritoneal  sac,  bacterial 
infection  necessarily  results,  usually  in  irresistible  strength.  Should  the 
inflammation  preceding  perforation  have  induced  a  local  condition  of 
peritonitis  by  extension  sufficient  to  cause  the  formation  of  circumscribing 
adhesions,  the  peritonitis  following  perforation  may  be  rigidly  localised. 
If  not,  the  resulting  attack  is  general.  When  abscesses  burst  and  dis- 
charge their  contents  into  the  peritoneal  cavity,  the  type  of  peritonitic 
inflammation  set  up  varies  with  their  nature  and  the  amount  evacuated. 
Pus  in  the  pericecal  and  appendicular  regions  always  contains  other 
organisms  in  addition  to  pyogenic  forms. 

Perforation  of  the  wall  of  the  stomach  or  bowel,  with  escape  of  their 
contents  into  the  peritoneal  sac;  obstruction  and  strangulation  of  some 
portion  of  the  gut,  from  hernia,  constriction,  volvulus,  and  other  causes ; 
appendicitis,  with  or  without  rupture  or  gangrene ;  inflammatory  affections 
of  the  pelvic  organs,  particularly  in  females — such  are  most  frequently  the 
exciting  causes  of  acute  secondary  peritonitis.  When  the  result  of  rupture 
of  an  abscess  situated  close  to  the  peritoneal  coverings,  with  discharge  of 
pus  into  the  cavity,  a  diffuse  form  of  suppurative  peritonitis  may  be  present, 
or,  if  inflammatory  changes  in  the  immediate  neighbourhood  of  the  abscess 
induce  formation  of  peritoneal  adhesions  before  rupture,  be  strictly  localised. 
Acute  suppurative  peritonitis,  however,  often  occurs  without  actual  rupture 
of  an  abscess ;  generally  in  such  cases  being  localised.  The  common  peri- 
typhlitic  and  appendicitic  abscesses,  originating  from  passage  of  organisms 
through  acutely  inflamed  coats  of  the  bowel,  form  well-known  instances  of 
this. 

The  acute  forms  of  peritonitis  occasionally  met  with  in  cancerous, 
tuberculous,  and  hydatid  infections  will  be  discussed  below.  Of  355  cases 
of  acute  secondary  peritonitis,  collected  by  me  from  the  records  of  the  Edin- 
burgh Eoyal  Infirmary  from  1892  to  1899,  183  were  male,  172  female.     In 


DISEASES  OF  THE  PERITONEUM.  805 

males,  lesions  of  the  appendix  and  neighbouring  tissues  were  by  far  the  most 
frequent,  followed  by  ulceration  of  the  intestine  and  then  by  intestinal 
obstruction.  Gastric  ulcer,  on  the  other  hand,  occupied  the  first  place 
among  the  females,  appendicitic  disease  second,  closely  followed  by  ob- 
struction of  the  bowel.  Among  the  females,  again,  pelvic  diseases  were 
answerable  for  almost  as  large  a  proportion  as  intestinal  obstruction  in 
males.  A  greater  proportion  of  cases  originated  from  gastric  cancer  in 
males  than  in  females,  and  the  converse  in  connection  with  intestinal  cancer. 

Morbid  anatomy. — The  peritoneal  coats  in  acute  peritonitis  show 
all  the  typical  changes  common  to  inflammatory  processes.  The  endothelial 
cells  covering  the  portion  affected  multiply,  enlarge,  and  often  desquamate 
(Orth).  Treatment  of  the  normal  peritoneal  surface  with  a  solution  of 
nitrate  of  silver  results  in  the  decolorisation  of  only  a  few  of  the  endothelial 
cells;  but  after  even  slight  artificial  irritation  during  life,  a  very  much 
larger  number  of  cells  become  thus  discoloured.  Delbet  regards  the  cells 
thus  altered  as  about  to  desquamate.  Wider  and  wider  interspaces  also 
appear  between  the  cells,  corresponding  to  the  degree  of  irritation  they  are 
submitted  to.  The  desquamating  cells,  before  their  actual  shedding,  often 
proliferate,  a  fact  which  probably  explains  the  rapidity  with  which  pus 
sometimes  appears  in  the  peritoneal  cavity.  The  underlying  connective 
tissue  also  is  swollen,  oedematous ;  its  cells  proliferate,  and  throw  out  a 
fibrinous  exudation. 

The  Bacillus  coli  communis  is  a  common  inhabitant  of  abdominal 
abscesses,  along  with  the  pyogenic  micrococci.  In  suppurative  peritonitis 
of  puerperal  origin  the  Streptococcus  pyogenes  predominates;  after  opera- 
tion, the  last-named,  along  with  the  Staphylococcus  pyogenes  aureus  and 
alius.  The  gonococcus  also  has  been  found  in  the  peritoneum,  in  cases 
caused  by  spread  of  infection  from  the  female  uterine  adnexa.  In  a  few 
instances  it  is  recorded  to  have  reached  the  peritoneum  in  the  male  from 
the  seminal  vesicles  or  spermatic  cord. 

Flexner  has  recorded  two  cases  in  which  the  Micrococcus  lanceolatus  was 
present  in  the  bowel  and  found  in  the  peritoneal  cavity,  where  it  had  given 
rise  to  acute  and  fatal  peritonitis,  although  there  was  no  rupture  of  the 
bowel.  Diplococci  of  pneumonia  have  been  found  in  great  numbers  in  the 
inflamed ,  peritoneal  cavity,  and  the  Amoeba  coli  identified  amongst  the  thin 
fibrinous  peritoneal  exudations  of  amoebic  dysentery  (Osier). 

Symptoms. — The  mode  of  onset,  the  area  of  membrane  involved,  the 
nature  of  the  inflammatory  process  and  of  the  exudate,  and  the  complicatory 
lesions,  vary  the  incidence  and  characters  of  acute  peritonitic  symptoms. 
Intense  pain,  shock,  and  symptoms  of  profound  collapse  usually  follow 
sudden  infection  of  the  peritoneum,  such  as  accompanies  external  wounds, 
perforation  of  a  gastric  ulcer,  or  rupture  of  the  bowel.  Irritation  of  the 
local  nervous  mechanism  of  the  peritoneum  may  be  so  severe  as  reflexly  to 
lead  to  a  rapidly  fatal  result,  not  only  in  cases  directly  infected  by  contents 
from  the  alimentary  canal,  but  also  in  traumatic  injuries,  even  without 
actual  wounding  of  the  peritoneum.  Occasionally,  perforation  of  an  empty 
viscus  is  unaccompanied  by  pain  or  shock,  acute  symptoms  subsequently 
arising  on  the  arrival  of  food-stuffs  at  the  seat  of  injury.  Still  more  rare 
are  those  cases  in  which  the  peritoneum  appears  to  be  incapable  of  painful 
sensations  throughout  the  attack. 

The  abdominal  pain  varies  in  position  with  the  primary  site  of  infection, 
but  generally  most  acute  at  or  immediately  beneath  the  umbilicus,  and  felt 
less  intensely  over  the  whole  abdomen.     If  the  cause  be  perforation  of  the 


806  ALIMENTARY  SYSTEM. 

stomach  wall,  the  pain  may  be  referred  to  the  back  or  shoulders ;  if  appendi- 
citic  or  typhlitic,  to  the  umbilical  region  at  first,  but  later  on  over  the  right 
iliac  fossa.  Not  uncommonly  subjective  pain  is  absent  as  long  as  perfect 
rest  is  maintained  in  the  posture  which  proves  to  be  the  most  comfortable 
and  easy. 

Vomiting  is  an  early  symptom,  and  a  most  painful  one,  because  of  the 
strain  and  pressure  put  on  the  inflamed  peritoneum.  The  vomit  is  often 
bile  stained;  during  the  later  stages,  it  may  be  composed  of  pure  bile, 
sometimes  of  fsecal  matter.  The  bowels  are  at  first  inclined  to  be  loose, 
but  shortly  become  constipated.  The  constipation  is  largely  due  to  a 
paralysis  of  peristalsis,  with  stasis  of  the  intestinal  contents — a  condition 
facilitating  great  evolution  of  gas,  and  leading  to  the  tympanites  which  is 
so  marked  a  feature  of  most  acute  peritonitic  attacks. 

The  patient  almost  invariably  assumes  the  dorsal  decubitus,  lying  on  his 
back  with  the  knees  drawn  up  to  lessen  the  tension  of  the  abdominal  walls, 
his  face  pinched  and  drawn,  anxious  and  suffering  in  expression,  a  malar 
flush — in  fact  the  typical  "fades Hippocratica"  suggestive  often  of  a  graver 
condition  than  in  fact  is  present. 

The  respirations  are  hurried,  shallow,  and  entirely  thoracic ;  the  pulse 
quick,  at  or  over  90  beats  per  minute ;  the  temperature  rarely  above  100°  F. 
As  the  attack  progresses  the  breathing  becomes  even  more  superficial ;  the 
pulse  rate  rises  to  110  or  up  to  140  per  minute,  the  beats  being  sometimes 
small  and  "  wiry  " ;  the  body  temperature  mounts  up  to  from  103°  to  105°  F. 
In  some  cases,  difficult  of  diagnosis,  no  rise  of  temperature  may  occur, 
while  the  pulse  gives  no  special  indication. 

The  tongue  at  first  is  moist  but  white — furred  ;  latterly  dry,  angrily  red, 
cracked  and  fissured.  The  abdomen  is  distended,  its  walls  rigid,  resenting 
change  of  form  or  position.  If  the  walls  are  thin,  the  forms  of  intestinal 
coils  blown  up  with  gas  may  be  traced  on  the  surface.  A  tympanitic 
percussion  note  may  be  obtained  over  the  greater  portion  of  the  abdomen, 
obscuring  the  splenic  dulness,  and  partially  obliterating  the  hepatic  dull 
area,  often  to  outside  of  the  mammary  line.  Where  gases  have  escaped 
into  the  sac  along  with  the  contents  of  the  stomach  or  bowel,  a  condition 
known  as  pneumo-peritoneum,  the  liver  dulness  may  be  almost  wholly 
obscured.  "When  the  tympanites  is  great  the  diaphragm  is  pushed  upwards, 
the  heart  displaced,  and  respiration  embarrassed.  The  earlier  rigidity  of  the 
abdominal  walls  may  be  succeeded  by  relaxation,  accompanied  by  great 
tumescence  and  distension. 

Some  effusion  of  fluid  is  usual  in  acute  peritonitis  ;  the  amount  is 
seldom  very  large,  and  is  often  confined  to  one  spot  by  adhesions. 
Occasionally  peritonitic  friction  may  be  heard  over  the  abdomen  in  acute, 
but  much  less  often  than  in  chronic  cases. 

Diagnosis. — As  a  rule  the  diagnosis  of  acute  peritonitis  is  attended 
with  no  great  difficulty.  The  antecedent  history  of  some  disease  or  injury 
of  the  alimentary  canal  conducive  to  rupture  or  perforation  of  the  wall, 
the  sudden  onset  of  the  attack,  the  local  and  general  symptoms ;  above  all, 
the  rigidity  of  the  abdominal  wall  and  the  characteristic  decubitus  assumed, 
serve  to  indicate  the  nature  of  the  disease.  In  idiopathic  cases,  the  con- 
junction of  some  debilitating  disease  with  the  classical  symptoms  of  acute 
peritoneal  inflammation,  a  history  of  exposure  or  local  contusion  along 
with  some  constitutional  ailment  or  intestinal  error,  signify  the  condition 
present.  The  thoracic  type  of  breathing,  the  rapid,  "  wiry  "  pulse,  and  the 
facial  expression,  aid  in  diagnosis. 


DISEASES  OF  THE  PERITONEUM.  807 

Prognosis. — Acute  idiopathic  peritonitis  is  very  fatal  if  a  com- 
plication of  chronic  disease  of  other  organs.  In  those  cases  in  which  it 
occurs  without  apparent  cause  or  complication,  the  prognosis  depends  upon 
the  general  condition  of  health  of  the  individual  attacked.  As  a  rule, 
recovery  results  without  surgical  interference  or  may  follow  operation ;  but 
where  prolonged  constipation  or  intestinal  dyspepsia,  with  acute  intoxication, 
has  previously  existed,  it  may  be  rapidly  fatal. 

The  earlier  surgical  measures  are  adopted  after  the  diagnosis  of  acute 
peritonitis  has  been  made,  the  more  favourable  the  prognosis.  The  mortality 
after  such  operations,  and  solely  due  to  them,  is  so  small  under  careful 
conditions,  that  it  may  be  disregarded  when  the  chance  of  recovery  from 
the  disease  is  considered,  and  the  high  mortality  caused  by  the  disease 
itself,  with  or  without  operation,  has  been  discounted. 

Treatment. — It  is  hardly  too  much  to  say  that  the  correct  treatment 
of  acute  peritonitis,  whatever  it  arise  from,  lies  in  calling  in  a  surgeon,  and 
the  performance  by  him  of  abdominal  section.  Whether  the  operation  be 
undertaken  for  exploration  only,  or  be  remedial  in  aim,  the  risks  attendant 
upon  the  disease  itself  far  outweigh  those  of  antiseptic  laparotomy;  the 
chances  of  benefit  from  surgical  measures  exceed  those  derivable  from 
purely  medicinal  treatment.  The  details  of  the  operations  appropriate 
under  various  circumstances  relate  rather  to  surgery  than  to  medicine,  and 
can  scarcely  be  entered  upon  here.  One  point  which  has  not  received  as 
much  attention  as  it  merits,  may  be  mentioned — the  valuable  assistance 
the  physician  can  render  the  surgeon  in  the  preparation  of  the  patient  for 
operation,  not  in  minor  details  connected  with  the  state  of  the  bowels, 
or  the  ingestion  of  food,  but  in  removing  or  lessening  nervous  disturb- 
ance naturally  aroused  by  the  thought  of  the  coming  operation,  and  in 
strengthening  the  heart,  generally  weakened  both  by  reflex  influences  and 
by  the  actual  disease.  Co-operation  between  physician  and  surgeon  before 
and  after  abdominal  operations,  the  physician  assisting  the  surgeon  through 
his  previous  knowledge  of  the  patient's  bodily  health  and  idiosyncrasies,  is 
most  desirable ;  early  recognition  of  the  surgical  nature  of  all  peritonitic 
lesions,  incumbent  on  the  physician;  readiness  to  operate  unless  clearly 
contra-indicated,  proper  for  the  surgeon. 

Where  the  peritonitis  is  suppurative  in  form,  and  especially  if  localised, 
prompt  operative  interference  is  obligatory.  No  delay  is  permissible  here. 
The  removal  of  purulent  exudations  may  possibly  effect  a  cure ;  the  opening 
of  a  localised  peritoneal  abscess  almost  invariably  does  so,  while  every 
minute  lost  increases  the  risk  of  rupture  of  the  adhesions  forming  part  of 
its  wall. 

The  medicinal  treatment  of  acute  peritonitis,  widely  employed  and 
recommended  before  operative  procedures  were  rendered  feasible  by  the 
introduction  of  antiseptic  surgery,  and  still  utilised  by  some,  is  founded  on 
two  diametrically  opposed  pharmacological  actions.  Thus  some  authorities 
advocate  the  administration  of  purgatives ;  others  the  exhibition  of  dru»s, 
especially  of  opium,  able  to  arrest  the  intestinal  peristalsis.  The  ad- 
ministration of  opium  preparations  or  of  morphine  has  undoubtedly  a 
marvellous  effect  in  subduing  pain  and  discomfort  in  acute  peritonitis,  and 
sometimes  even  appears  to  arrest  the  progress  of  the  inflammation.  In 
most  cases,  however,  the  arrest  of  peristalsis  established  tends  to  exaggerate 
intestinal  stasis  and  fermentation,  and  to  increase  the  toxa?mia  present. 
In  the  so-called  idiopathic  cases  especially,  opium  and  its  derivatives 
may  render  the  source  of  infection  more  potent. 


808  ALIMENTARY  SYSTEM. 

The  exhibition  of  purgatives  in  acute  peritonitis  only  applies  to  cases  in 
which  no  perforation  of  the  gut  has  occurred.  In  simple  cases,  without 
any  gross  peritoneal  lesion,  where  absorption  of  bacteria  or  toxines  from  the 
bowel  forms  the  principal  source  of  infection,  bland  purgatives  given  early 
may  abort  an  attack  by  removing  irritating  scybala  or  fermenting  contents 
from  the  bowel.  If  opium  be  used  it  should  be  given  in  large  doses, 
sufficient  to  place  the  patient  thoroughly  under  the  influence  of  the  drug, 
when  the  absence  of  intestinal  movements  and  the  abolition  of  painful 
sensations  lessen  the  irritation  of  the  peritoneum  and  inhibit  the  abnormal 
stimuli  reflexly  produced  by  the  local  nerve  fibrils.  Bland  aperients, 
castor-oil  for  preference,  combined  with  small  doses  of  opium,  to  prevent 
any  excessive  peristalsis,  may  be  given  early  in  an  attack.  This  combina- 
tion generally  produces  one  or  two  soft  motions,  without  causing  pain.  In 
all  those  cases  which  are  the  result  of  local  inflammation  in  the  wall  of  the 
bowel,  owing  to  faecal  stasis  or  impaction,  where  abnormal  numbers  of 
bacteria  are  enabled  to  gain  the  peritoneal  cavity,  and  peritoneal  absorption, 
may  be,  is  diminished,  and  in  which  absorption  of  intra-intestinal  bacterial 
toxines  is  increased,  an  early  evacuation  of  the  bowel,  provided  the  means 
used  to  this  end  cause  little  irritation,  removes  the  primary  source  of 
infection,  and  may  suffice  to  quell  it ;  the  peritoneum  being  capable  of 
dealing  with  the  inflammatory  condition  affecting  it,  when  further  accession 
of  toxic  agents  is  prevented. 

The  local  application  of  ice  to  the  abdomen  often  soothes  pain  and 
relieves  distressing  symptoms.  Heat  acts  in  much  the  same  way,  but  is 
not  so  suitable  owing  to  its  tendency  to  encourage  suppuration  while 
relieving  pain.  Counter-irritation  is  seldom  of  any  avail,  unless  the 
peritonitis  be  very  local  in  character,  and  independent  of  gross  lesions. 
The  ascitic  fluid  present  in  acute  peritonitis  rarely  reaches  a  point  neces- 
sitating aspiration ;  in  fatal  cases  it  usually  persists  to  the  end ;  in  others 
is  generally  absorbed  during  the  process  of  recovery,  or  becomes  larger  as 
acute  attacks  pass  into  chronic  forms. 

Should  the  tympanites  become  so  pronounced  as  to  threaten  life  by 
interference  with  the  actions  of  thoracic  viscera,  a  trocar  or  cannula 
plunged  into  a  distended  coil  of  the  bowel  will  allow  the  escape  of  some  of 
the  gas.  The  great  distension  of  the  bowel  and  the  increased  pressure 
within  the  abdominal  cavity  render  the  entrance  of  a  trocar  a  matter  of 
much  greater  ease  than  when  the  intestines  are  flaccid  and  freely  movable 
within  it. 

The  diet  in  acute  peritonitis  should  be  mainly  confined  to  milk,  raw  or 
boiled,  and  in  small  quantities  at  a  time;  diluted  with  water,  or  soda- 
water,  or  peptonised.  Vegetable  substances  must  be  eschewed;  meats 
well  cooked,  finely  divided  or  thoroughly  masticated,  and  in  small  amounts, 
do  no  harm;  meat  extracts  are  allowable.  Stimulants  are  indicated  in 
some  cases,  contra-indicated  in  others.  The  food  given  should  be  mainly 
in  fluid  form — milk,  predigested  or  raw,  meat  extracts,  egg-flip  with 
whisky,  brandy,  or  champagne  ;  but  nothing  in  large  amounts  at  one  time, 
always  "  little  and  often."  Hot  water,  however,  taken  as  hot  as  can  be 
swallowed  without  pain,  and  in  considerable  bulk,  should  it  be  retained, 
passes  into  the  bowel  undiminished  in  quantity,  and  often  aids  in  allaying 
peristaltic  paralysis  and  flatulent  distension,  while  exercising  a  beneficial 
effect  upon  the  peritoneum.  The  almost  invariable  accompaniment  of 
acute  peritonitis — evolution  of  large  quantities  of  gas  within  the  bowel — 
gives  rise  to  very  distressing  symptoms,  but  may  be  mitigated  by  the 


DISEASES  OF  THE  PERITONEUM.  809 

method  just  mentioned,  or  by  the  careful  introduction  of  a  soft  indiarubber 
tube  per  rectum  as  high  up  the  large  bowel  as  possible,  irrigation  of  the 
bowel  with  water  at  the  body  temperature,  and  by  maintenance  of  the 
tube  afterwards  in  position  to  allow  of  the  expulsion  of  gas ;  endeavouring 
as  far  as  possible  by  change  of  posture  to  facilitate  its  passage  from  the 
colon.  Frequently,  if  the  patient  be  propped  up  lying  upon  his  left  side, 
after  irrigation  has  been  performed,  passage  of  gas  from  the  small  intestine 
into  the  large  follows  the  removal  of  the  latter's  contents ;  then  a  change 
on  to  the  right  side  tends  to  pass  the  gas  on  towards  the  open  end  of  the 
tube,  whence  without. 

Chronic  Peritonitis. 

Etiology  and  morbid  anatomy. — Chronic  inflammation  of  the 
peritoneal  serous  and  sub-serous  coats,  generally  characterised  by  the 
formation  of  adventitious  fibrous  tissue,  often  by  the  collection  of  fluid 
in  the  peritoneal  cavity. 

Primary  chronic  peritonitis. — It  has  already  been  argued  that  the 
so-called  acute  idiopathic  peritonitis  is  caused  most  probably  by  in- 
cursions of  bacterial  agents  or  poisonous  toxines,  without  visible  solution 
of  continuity  of  the  lining  membrane  of  the  peritoneal  cavity.  The  same 
arguments  apply  to  the  chronic  forms  of  peritonitis  provisionally  classed 
under  a  similar  heading.  Cases  of  chronic  simple  peritonitis  belong  to  two 
different  types — the  local  adhesive  and  the  proliferative. 

Chronic  local peritonitic  adhesions  are  very  common,  frequently  give  rise 
to  no  morbid  symptoms  of  import  during  life — generally,  indeed,  are  just  dis- 
covered on  autopsy — particularly  affect  the  splenic  and  hepatic  regions,  but 
may  occur  in  any  part,  and  between  any  two  opposing  areas  of  peritoneum, 
and  appear  apart  from  any  previous  attack  of  acute  peritonitis.  The  manner 
in  which  the  peritoneal  membrane  manufactures  those  adhesions  is  a 
disputed  question.  Some  authorities  regard  the  production  and  exudation 
of  lymph  as  the  work  of  the  connective  tissue  cells,  situated  immediately 
beneath  the  endothelial  layer,  whenever  the  cells  of  the  latter  have  suffered 
loss  of  vitality,  or  have  been  actually  removed.  By  this  production  of 
lymph  the  subjacent  cells,  deprived  of  their  natural  line  of  defence,  or 
left  with  but  a  weakened  bulwark,  endeavour  to  lessen  the  irritation  caused 
by  contact  with  and  friction  from  other  peritoneal  surfaces,  continuously 
kept  in  motion  by  peristaltic  contractions,  by  securing  greater  fixity  of 
position,  and  abolishing  the  possibility  of  injury  from  attrition.  Others, 
again,  regard  local  endothelial  loss  or  decay  and  the  production  of  lymph 
as  contemporaneous,  and  the  result  of  one  and  the  same  cause. 

Whichever  of  these  views  represents  the  truth,  or  it  lie  between,  or 
outside  them,  it  may  be  said  with  certainty  that  chronic  adhesions  can 
scarcely  be  initiated  in  loco,  but  can  only  result  from  some  actual 
irritation  produced  by  a  poisonous  agency  within  the  sac,  or  in  the  tissues 
immediately  adjacent  to  the  serous  membrane,  of  moderate  virulence,  but 
affecting  some  special  restricted  area  more  or  less  persistently.  The 
exuded  lymph  rapidly  becomes  organised,  and  forms  a  fibrous  connection 
between  two  peritoneal  surfaces.  Adhesions  which  connect  one  coil  of  the 
small  gut  to  another  are  usually  short,  but  those  in  other  parts  often  are 
stretched  out  into  definite  fibrous  bands  in  cases  of  long  standing. 

-  Very    probably,  in    acute    attacks    of    enteritis    and  gastro-enteritis, 
excessive  intestinal  fermentation,  and  in  cases  of  chronic  constipation,  in 


810  ALIMENTARY  SYSTEM. 

all  of  which  greater  numbers  of  bacteria,  and  larger  amounts  of  toxines 
penetrate  the  intestinal  mucous  membrane,  and  gain  access  to  the  peritoneal 
membrane  and  cavity,  areas  of  endothelial  insufficiency  occur,  leading  to 
lymph  formation ;  the  symptoms  of  acute  peritonitis  persisting  after 
subsidence  of  the  enteritic  attack,  owing  to  diminished  power  of  checking 
bacterial  invaders  where  the  serous  layer  is  weakened. 

Chronic  'proliferative  peritonitis,  even  better  called  peritoneal  cirrhosis ; 
and  in  many  cases,  hypertrophic  peritoneal  cirrhosis. — In  this  condition 
the  peritoneal  membrane,  in  all  its  layers  and  usually  over  its  entire 
surface,  is  thickened  and  hardened.  Its  serous  surface  shows  opaquely 
white.  The  thickening  is  not  uniform  in  degree ;  in  some  places  it  is 
greater  than  in  others.  Adhesions  are  seldom  a  prominent  feature.  Local 
forms  have  been  separately  described  under  the  names  of  chronic 
perihepatitis  and  chronic  perisplenitis,  in  which  the  peritoneal  capsule  of 
the  liver  and  spleen  respectively  are  thickened,  sometimes  enormously.  A 
depth  of  as  much  as  half  an  inch  has  been  recorded  in  such  cases.  In 
most  instances  the  increase  in  thickness  of,  and  hypertrophy  of  connective 
tissue  elements  in,  the  capsules  of  these  organs  is  directly  connected  with 
cirrhotic  changes  in  the  substance  of  the  glands. 

The  thickening  of  the  omental  coats  is  usually  marked,  and  is 
commonly  followed  by  a  rolling  up  of  this  portion  of  the  peritoneum  upon 
itself,  and  the  presence  of  a  resistant  mass  lying  transversely  across  the 
abdomen  immediately  below  the  stomach,  and  above  or  over  the  transverse 
colon,  and  readily  discovered  on  palpation.  Again,  the  mesentery  may  be 
so  shortened  and  contracted  by  this  hypertrophy  of  its  tissues  that  the 
intestinal  coils  are  closely  drawn  together,  and  may  even  appear  as  a  ball 
of  no  great  size  in  the  centre  of  the  abdomen. 

Secondary  chronic  peritonitis.—  This  may  be  a  sequel  of  acute 
peritonitis,  diffuse  adhesive  peritonitis. — Often  after  apparent  recovery  from 
an  attack  of  acute  peritonitis,  obscure  and  indefinite  symptoms  of  abdominal 
unrest  persist,  or  may  appear  at  some  period  or  other  afterwards.  Their 
origin  is  not  far  to  seek.  The  history  of  a  former  acute  attack  will  point 
to  their  causation.  During  the  course  of  every  acute  attack  of  peritonitis 
a  certain  quantity  of  inflammatory  exudation  is  produced  by  the  peritoneal 
cells,  varying  in  degree  with  the  nature  of  each  attack.  The  lymph  thus 
exuded  may  or  may  not  become  organised,  and  in  course  of  time  form 
fibrous  adhesions.  Generally  speaking,  the  inflammatory  adhesions  of  acute 
peritonitis  are  many  but  weak,  matting  the  intestines  together,  joining 
them  with  the  omentum,  and  connecting  them  with  the  parietal  surface. 
When  these  adhesions  become  more  firm  and  fibrous  at  a  later  date,  they 
naturally  are  liable  to  interfere  with  the  peristaltic  movements  of  the  bowel, 
and  prevent  freedom  in  change  of  site  or  bulk  on  the  part  of  the  viscera. 
Irregularity  of  bowel  function  follows,  dragging  sensations  variously 
located  may  occur,  and  intestinal  flatulent  colic  readily  produced,  owing  to 
hindered  motility  of  the  coils  of  the  gut. 

Symptoms. — The  symptoms  of  chronic  peritonitis  are  capricious. 
The  only  one  which  can  be  termed  constant  is  the  presence  of  fluid  in 
the  abdominal  cavity.  There  may  be  no  sign  of  constitutional  disturbance, 
no  loss  of  flesh,  or  of  strength ;  or  the  patient  may  become  emaciated,  pale, 
and  dyspeptic.  Fever  is  rare,  pain  and  tenderness  inconstant.  The 
abdomen,  however,  is  enlarged,  distended,  often  enormously ;  and  yields  all 
the  signs  and  indications  of  the  presence  of  free  fluid  within  it.  The 
degree  of  enlargement  usually  increases  gradually  through  the  course  of 


DISEASES  OF  THE  PERITONEUM.  811 

some  months,  now  and  then  of  as  many  weeks ;  often  exhibiting  variations 
in  rate  of  increase  from  time  to  time,  or  even  some  decrease  in  actual  bulk, 
following  and  followed  by  extension.  In  all  forms  of  chronic  peritonitis  a 
friction  rub  may  generally  be  detected  over  the  upper  part  of  the  abdomen, 
caused  by  contact  between  adhesions. 

After  disappearance  of  the  fluid,  by  absorption  or  after  aspiration, 
masses  of  irregular  shape  may  be  palpated  in  the  abdomen,  consisting  of 
peritoneal  thickenings,  areas  surrounded  by  dense  adhesions,  or  of  a  draw- 
ing together  of  the  intestines  by  reason  of  shortening  of  the  mesentery. 

Treatment. — Medicinally,  tonics,  iron,  arsenic,  quinine,  and  strych- 
nine ;  hydragogue  cathartics,  especially  salines  ;  and  diuretics  are  indicated ; 
along  with  light  nourishing  foods.  If  under  such  measures  the  fluid  shows 
no  inclination  to  diminish,  aspiration  gives  the  most  satisfactory  results ; 
in  several  cases  has  been  followed  by  cure.  After  disappearance  of  the 
fluid,  gentle  abdominal  massage  may  prove  of  service  in  lessening  the  dis- 
comfort due  to  the  presence  of  adhesions,  rendering  them  less  rigid,  and 
aiding  the  intestinal  freedom  of  movement. 

Tuberculous  Peritonitis. 

Tuberculous  invasion  of  the  peritoneum  may  either  be  acute  or 
chronic,  localised  or  general,  primary  or  secondary.  In  the  rare  cases 
which  may  be  termed  primary,  the  peritoneal  membrane  is  the  seat  of 
active  tuberculous  processes,  generally  displayed  in  the  form  of  tuber- 
culous nodules  spread  over  its  surface;  when  acute,  usually  of  small 
size  but  in  enormous  numbers ;  when  chronic,  fewer  and  larger,  and 
perhaps  more  often  localised  in  one  part.  In  secondary  cases,  in  which 
invasion  of  the  peritoneum  follows  directly  upon  infection  from  previous 
tuberculous  processes  in  other  tissues,  their  distribution  and  their  intensity 
depend  upon  the  virulence  of  the  infective  poison.  The  resulting  invasion 
may  be  purely  local  and  circumscribed,  and  of  a  chronic,  inactive  nature, 
or  may  rapidly  spread  over  all  the  peritoneal  surface  in  an  acute  form. 
The  acute  forms  are  rarely  met  with  except  in  cases  of  general  miliary 
tuberculosis. 

Etiology. — Although  most  frequently  met  with  in  the  young,  tuber- 
culous peritonitis  often  occurs  in  adults — oftener,  perhaps,  than  is  commonly 
supposed.  It  is  usually  asserted  that  males  are  more  often  attacked  than 
females,  but  the  records  of  the  Edinburgh  Eoyal  Infirmary  show  practically 
an  equality  between  the  sexes — 144  to  142  ;  although  under  the  age  of  9, 
males,  and  above  19,  females,  are  distinctly  the  more  numerous.  Osier 
noted  in  the  statistics  of  laparotomies  for  tuberculous  peritonitis  collected 
by  him,  that  females  and  males  were  as  2  to  3.  The  same  authority, 
analysing  357  cases  collected  from  the  literature  of  the  subject,  found  the 
ages  of  346  to  be  as  shown  in  the  table. 

The  proportion  of  cases  recorded  under  the  several  ten-year  periods  in 
the  two  series  differs  radically.  In  the  Edinburgh  series  the  numbers 
registered  during  the  first  two  decades  of  life  are  far  above  Osier's  corre- 
sponding figures ;  while  the  converse  holds  true  for  all  the  following 
periods.  Thus  the  number  treated  in  Edinburgh  between  the  ages  of  10 
and  19  formed  45  per  cent,  of  the  total;  under  9  years,  227  per  cent.; 
Osier's  figures  for  these  decades  yielding  only  21 -67  per  cent,  and  7 -8 
per  cent,  respectively.  The  large  number  of  cases  shown  in  Osier's  statistics 
over  the  age  of  40  is  surprising.     There  was  a  marked  predominance  of 


812  ALIMENTARY  SYSTEM. 

cases  in  males  below  the  age  of  10,  an  equality  in  number  between  the 
two  sexes  from  10  to  20,  and  thereafter  a  larger  number  of  female  cases. 

The  statistics  of  operations  for  tuberculous  peritonitis  hitherto  gives 
females  a  large  majority ;  those  of  post-mortem  records  an  equally  high 
proportion  in  favour  of  males.  Thus  Osier,  from  collected  statistics  of 
laparotomies,  found  the  number  of  female  cases  to  be  131,  of  males  only 
half,  or  sixty.  Konig,  in  a  series  of  131  operations,  records  only  eleven 
men  against  120  women,  or  1  to  11.  Among  the  286  cases  from  the 
Edinburgh  Royal  Infirmary  records,  the  proportion  of  males  to  females  in 
the  sixty -eight  cases  operated  upon  was  much  higher — 31  to  37.  Com- 
bining these  various  figures,  out  of  a  total  of  390  laparotomies,  288  were 
female,  only  102  male — a  proportion  of  almost  three  to  one. 

On  the  other  hand,  of  107  post-mortems  analysed  by  Curtis,  eighty- 
nine  were  on  males,  eighteen  on  females.  The  Edinburgh  figures  again 
fail  to  correspond — nine  males  to  thirteen  females. 

Tuberculous  peritonitis  often  accompanies  pulmonary  tuberculosis, 
frequently  along  with  tuberculous  enteritis,  and  in  cases  of  tabes  mesen- 
terica.  Tuberculous  infection  of  the  abdominal  lymphatic  glands,  especially 
of  those  situated  in  the  mesentery,  leads  frequently  to  direct  peritoneal 
infection,  when  a  caseous  gland  ruptures  into  the  sac.  In  women,  direct 
invasion  often  proceeds  from  the  Fallopian  tubes ;  in  men,  extension  of 
tuberculous  processes  has  been  noted  from  the  vas  deferens.  Phillips  gives 
74  per  cent.,  Pribram  53  per  cent.,  and  Sick  65  per  cent.,  as  the  relative 
frequency  of  intestinal  infection ;  the  latter  according  the  female  pelvic 
organs  with  26  per  cent.,  Osier  with  from  30  to  40  per  cent,  Pribram  with 
only  4'8  per  cent,  out  of  165  cases.  Osier,  from  the  results  of  seventeen 
autopsies,  concludes  that  in  five,  or  294  per  cent.,  the  tuberculous  condition 
was  truly  of  primary  origin.  From  observation  of  107  autopsies,  Konig 
records  concomitant  tubercle  of  the  lungs  in  92-5,  the  pleura  in  56-04,  the 
intestine  in  74*72,  the  peritoneal  lymphatic  glands  in  41 '09,  the  spleen  in 
37'36,  the  kidneys  in  35-49,  and  the  liver  and  adrenals  in  each  56  per  cent. 

Morbid  anatomy. — In  the  ordinary  chronic  variety,  groups  of 
tuberculous  nodules  coalesce  to  form  larger  masses,  of  different  sizes, 
usually  flattened  in  shape,  and  becoming  caseous.  Adhesions  may  stretch 
between  the  various  peritoneal  surfaces,  which  in  turn  are  frequently 
thickened.  In  the  fibroid  form  the  nodules  are  harder  and  not  aggregated 
in  masses,  while  the  serous  surfaces  are  matted  together  by  numerous 
fibrous  adhesions.  The  exudation  in  the  first  form  may  be  purulent  or 
sero-purulent ;  in  the  second  it  is  seldom  large  in  amount,  often  absent. 

Symptoms. — Chronic  tuberculous  peritonitis  not  infrequently  gives 
rise  to  few  symptoms  of  moment  for  a  considerable  period  of  time  after 
the  actual  commencement  of  the  disease.  It  may  indeed  be  latent,  and 
only  discovered  during  an  operation  or  post-mortem.  The  more  gradual 
the  onset,  the  longer  the  course  of  the  disease.  The  commoner  symptoms 
include  abdominal  pain,  slight  or  severe,  circumscribed  or  diffuse,  with  or 
without  tenderness ;  enlargement  of  the  abdomen,  general  or  localised ; 
and  pyrexia  of  a  cachectic  type,  seldom  intense,  often  in  fact  replaced  by, 
or  alternating  with,  periods  of  subnormal  temperature.  The  abdominal 
swelling  may  be  caused  by  collection  of  fluid  in  the  peritoneal  sac,  by 
tympanites,  or  by  both  of  these  factors.  The  fluid,  if  in  large  amount, 
may  support  the  intestinal  coils  on  its  surface,  provided  that  they  are  not 
bound  down  by  adhesions ;  and  thus  afford  a  tympanitic  percussion  note, 
varying  in  site  and  area  with  the  decubitus,  over  the  position  of  the  float- 


DISEASES  OF  THE  PERITONEUM.  813 

ing  bowel,  surrounded  by  a  dull  region  similarly  changing  in  size  and  place. 
When,  as  often  happens,  the  exudate  is  encapsulated  by  peritoneal 
adhesions,  the  presence  of  cystic  tumours  may  be  suggested.  Distension 
of  portions  of  the  bowel  with  gas,  in  connection  with  such  localised 
effusions  and  adhesions,  may  appear  as  elastic,  rounded  tumours,  which  do 
not  show  changes  in  site  on  altering  the  position  of  the  body.  As  the 
formation  of  adhesions  proceeds  as  a  rule  pari  passu  with  the  course  of  the 
disease,  symptoms  of  disturbance  of  digestion,  from  their  interference  with 
the  mobility  and  motility  of  the  gut,  are  more  and  more  liable  to  appear 
— loss  of  appetite,  dyspepsia,  reflex  nausea,  diarrhoea,  or  constipation. 
Obstruction  of  the  bowel  may  be  a  result.  In  addition,  save  in  the 
latent  cases,  increasing  emaciation  and  debility  mark  the  progress  of 
the  disease. 

An  elongated,  sausage-like,  firm  mass,  lying  across  the  upper  part  of 
the  abdomen,  easily  palpable,  usually  dull  on  percussion,  but  occasionally 
resonant  owing  to  interposition  of  a  coil  of  intestine,  sometimes  found 
in  the  right  iliac  region,  denotes  the  omentum,  thickened,  contracted, 
and  rolled  on  itself.  Met  with  in  cancer  and  chronic  cirrhosis  of  the 
peritoneum,  it  is  more  common  in  tuberculous  peritonitis. 

Diagnosis. — Perhaps  the  difficulties  attendant  upon  the  diagnosis  of 
chronic  tuberculous  peritonitis  may  be  correctly  said  to  increase  with  the 
age  of  the  patient.  In  the  young  it  is  seldom  a  difficult  problem  to  decide 
upon.  In  patients  of  greater  age,  especially  in  women,  the  large  number 
of  laparotomies  undertaken  for  the  removal  of  supposititious  ovarian  cysts, 
but  resulting  in  discovery  of  tuberculous  peritonitis,  renders  it  apparent 
how  readily  mistakes  can  be  made. 

A  careful  consideration  of  all  the  etiological  factors  offers  the  most 
valuable  evidence.  Non-tuberculous  chronic  peritonitis  often  simulates  the 
tuberculous  form  very  closely.  A  history  of  antecedent  tubercle  or  of 
pleurisy  with  effusion  may  point  out  its  true  nature.  The  general  absence 
of  fever  with  ovarian  tumours,  and  their  less  speedy  enlargement,  aid  in 
distinguishing  between  them  and  this  disease  ;  while  ascites  caused  by 
other  agencies  may  be  eliminated  by  determination  of  the  true  underlying 
lesion. 

Prognosis  must  always  be  guarded.  Osier  gives  25  per  cent,  as  the 
proportion  of  recoveries.  Some  authorities  regard  cases  with  exudation  as 
of  more  favourable  augury  than  those  without ;  others  hold  the  converse  to 
be  correct.  The  prognosis  is  undoubtedly  better  in  the  young  than  in 
adults,  but  no  case  can  be  regarded  as  other  than  serious  before  operative 
interference.  After  operation  it  is  generally  readily  determined  whether  a 
hopeful  result  is  possible  or  not. 

Treatment. — In  treating  cases  of  tuberculous  peritonitis,  much 
depends  upon  the  stage  to  which  the  disease  has  advanced,  and  upon  the 
virulence  of  the  attack.  In  chronic  and  subacute  tuberculous  peritonitis, 
whether  general  or  local,  treatment  in  the  earlier  stages  should  consist  in 
rich  dieting,  especially  in  fats,  in  avoidance  of  confined  atmospheres,  and  in 
enjoyment  of  open  air  life  as  far  as  possible.  Iodoform,  internally,  often  is 
of  benefit ;  and  mercurial  inunction  may  be  employed.  At  what  stage 
operative  interference  can  reasonably  be  resorted  to  is  a  question  which  is 
difficult  to  answer ;  when  performed  in  cases  of  considerable  severity, 
laparotomy  and  thorough  flushing  of  the  abdominal  cavity  have  often  been 
followed  by  the  best  results.  Logically,  the  earlier  such  treatment  is 
adopted  the  better  the  result.     But  so  many  cases  recover  under  medicinal 


8i4  ALIMENTARY  SYSTEM. 

and  dietetic  treatment,  that  the  risk  attendant  upon  all  abdominal  opera- 
tions can  scarcely  be  properly  encountered  when  the  disease  is  still  of 
early  stage.  Operative  interference  is  scarcely  to  be  recommended  where 
tuberculous  processes  in  other  organs  coexist.  If  the  origin  of  the  tuber- 
culous peritonitis  proceeds  by  direct  infection  from  one  or  other  organ,  or 
some  adjacent  tissue,  and  the  fact  be  clearly  recognised,  laparotomy  with 
the  view  of  removing  the  primary  source  should  be  at  once  performed ;  but 
if  the  source  be  doubtful,  while  possibly  of  such  a  nature,  an  exploratory 
operation  is  more  to  be  commended  than  reprehensible. 

No  method  of  treatment  is  of  much  avail  in  acute  tuberculous  peritonitic 
attacks.  These  are  usually  local  manifestations  of  a  general  infection; 
occasionally,  however,  confined  to  the  peritoneum.  In  both  instances  the 
potency  and  degree  of  virulency  possessed  by  the  causal  bacilli  render 
remedial  measures  useless. 

If  the  tuberculous  process  be  localised,  and  by  the  reparative  actions  of 
nature  confined  within  efficient  barriers,  evacuation  of  the  contents  and 
irrigation  of  the  cavity  generally  succeed  in  preventing  further  mischief. 
When  phthisis  pulmonum  coexists,  if  the  rational  methods  of  combating 
consumption  are  employed,  food  taken  often  and  to  some  degree  in  excess, 
should  it  be  simple  and  easy  of  assimilation,  along  with  a  constant  existence 
in  fresh  and  uncontaminated  air,  the  peritoneal  affection  will  usually  be 
cured  before  that  of  the  lung  ;  it  forms,  as  a  rule,  the  outcome  of  a  more 
attenuated  virus,  and  is  generally  more  amenable  to  treatment  than  the 
pulmonary  lesion. 

Tabes  Mesenterica. 

The  term  tabes  mesenterica  is  applied  to  tuberculous  infection  of  the 
mesenteric  glands,  and  by  many  is  regarded  as  distinct  from  tuberculous 
peritonitis.  A  number  of  authorities,  however,  do  not  differentiate  between 
them,  but  group  them  under  tuberculous  peritonitis.  In  truth,  tabes 
mesenterica  often  is  accompanied  by  tuberculous  peritonitis ;  tuberculous 
peritonitis  by  tabes  mesenterica ;  but,  on  the  other  hand,  examples 
are  certainly  met  with  in  children  in  which  no  symptoms  of  peritoneal 
infection  can  be  traced,  although  the  mesenteric  glands  are  undoubtedly 
affected. 

Etiology. — Tabes  mesenterica  is  a  disease  of  early  life,  and  in  nature 
closely  resembles  the  processes  so  commonly  met  with  in  tuberculous 
affections  of  superficial  lymphatic  glands  at  a  similar  age.  The  causal 
agents  of  infection  reach  the  glands  in  most  cases  from  the  intestine,  and 
apparently  may  often  do  so  apart  from  active  tuberculous  disease  in  the  . 
bowel  itself.  Lymphatic  glands  throughout  the  body  are  peculiarly  open 
to  tuberculous  infection  of  a  non-virulent  type,  when  all  the  other  tissues 
are  strong  enough  to  inhibit  growth  of  the  Bacillus  tuberculosis.  So,  in  the 
abdomen,  tuberculosis  of  the  peritoneal  glands,  uncomplicated  by  affection 
of  other  organs,  progresses  slowly,  does  not  tend  to  spread  further,  to  any 
great  extent,  unless  one  of  the  glands  ruptures  into  the  peritoneal  sac,  and 
is  very  amenable  to  appropriate  treatment. 

Symptoms. — If  the  attention  be  drawn  to  a  child  suffering  from  tabes 
mesenterica,  at  an  early  stage,  the  only  objective  symptoms  noticeable 
consist  in  a  slight  enlargement  of  the  abdomen ;  subjectively,  interrogation 
will  probably  extract  the  fact  that  the  little  patient  has  for  some  time 
before  shown  a  listlessness,  disinclination  to  play,  and  a  preference  for 
sitting  over  the  fire,  foreign  to  earlier  habits  and  to  those  natural  to  youth. 


DISEASES  OF  THE  PERITONEUM.  815 

The  appetite  does  not  diminish,  may  indeed  increase,  but  the  child  loses 
flesh  while  the  abdomen  enlarges.  Palpation  performed  firmly  will  reveal 
the  presence  of  a  sense  of  resistance  from  doughy  masses  collected  towards 
the  posterior  wall  of  the  abdomen.  If  the  condition  be  allowed  to  advance, 
the  abdominal  swelling  increases,  emaciation  of  the  rest  of  the  body  rapidly 
becomes  more  pronounced,  diarrhoea  sets  in,  and  death  follows  from 
exhaustion.  As  medical  officer  of  a  large  boarding-school,  in  which  children 
of  the  poorer  classes  are  admitted  when  about  7  years  of  age,  the  writer 
has  had  many  opportunities  of  observing  examples  of  abdominal  tuber- 
culosis under  very  favourable  circumstances, — in  a  number  of  cases  in 
which  sources  of  error  from  presence  of  tympanites  or  ascites  could  be 
clearly  eliminated;  in  which  palpation  and  percussion  of  the  abdomen 
revealed  the  presence  of  abnormal  masses,  painless,  soft,  amorphous,  hardly 
possible  the  result  of  lymphatic  obstruction  of  chyle ;  in  which  the  body 
weight  decreased,  the  temperament  altered,  the  appetite  increased,  and,  in 
some,  diarrhoea  occurred ;  and  in  which  fresh  air,  fats,  increased  nutriment, 
and  iodoform  speedily  occasioned  decrease  of  the  abdominal  masses,  with 
increase  of  the  body  generally  in  bulk  and  vigour,  followed  by  restoration 
to  health. 

Treatment. — Uncomplicated  cases  of  tabes  mesenterica  respond  to 
appropriate  treatment  almost  more  readily  than  any  other  tuberculous 
condition.  Secondary  infections  appear  to  be  rare  until  the  latest  stages 
are  reached.  As  insufficiency  of  diet  seems  to  be  the  cardinal  point, 
improved  food,  cod-liver  oil,  butter  or  cream,  fresh  air  and  exercise,  are 
essential  in  treatment.  As  to  drugs,  for  cod-liver  oil  is  a  food  not  a  drug, 
the  writer  has  obtained  more  good  by  the  internal  administration  of 
iodoform  in  from  1  to  3  gr.  doses  twice  or  thrice  a  day,  than  from 
any  other  medicine ;  especially  if  the  patient  be  allowed  to  go  about,  to  be 
outside,  to  partake  of  the  articles  of  his  ordinary  diet  in  amount  sufficient 
for  his  needs,  adding  to  it  some  form  of  fat  in  cod-liver  oil  or  cream ;  but  if 
possible  not  confined  to  bed  or  the  sickroom. 

As  tuberculous  affection  of  the  mesenteric  glands  is  closely  associated 
with  infection  of  the  peritoneal  membrane  itself,  treatment  beneficial  in  the 
first  acts  satisfactorily  in  the  second  form,  unless  the  latter  be  of  an  acute 
and  virulent  type.  Inunction  of  the  oleate  of  mercury  through  the  skin 
over  the  anterior  abdominal  wall  is  an  excellent  accessory,  or  the  soluble 
metallic  salts  of  mercury  lately  introduced  may  be  used  with  advantage. 

Malignant  Peeitonitis. 

Etiology  and  morbid  anatomy. — Primary  carcinoma  of  the 

peritoneum  or  of  the  peritoneal  lymphatic  glands  is  uncommon.  When 
it  does  occur  it  usually  resembles  primary  cancer  of  the  pleura,  that  is 
to  say,  it  is  an  endothelioma.  Nodules  of  unequal  size  stud  more  or  less 
closely  the  peritoneal  surface,  the  layers  of  which  are  greatly  thickened. 
Great  effusion  of  fluid  into  the  peritoneal  sac  often  follows,  generally  along 
with  a  deposition  of  fibrin ;  the  fluid  effused  frequently  containing  blood 
corpuscles  and  pigment. 

Secondary  carcinomata  of  the  peritoneum  are  very  common,  and 
either  occur  by  direct  extension  through  continuity  of  tissue,  or  are  due  to 
introduction  through  the  lymphatic  vessels  of  infective  material  from 
without.  Colloid  or  alveolar  cancer  elsewhere,  by  reason  of  its  rigid 
stroma  and  enlarged  cells,  is  rarely  accompanied  by  peritoneal  metastasis 


8 1 6  ALIMENTARY  S  YSTEM. 

through  lymphatic  transportation,  but  frequently  primary  growths  extend- 
ing through  the  walls  of  the  stomach  or  the  bowel  infect  and  penetrate 
the  peritoneal  coats.  Indeed,  no  secondary  form  of  cancer  so  commonly 
causes  secondary  peritoneal  growths  as  the  colloid  variety  when  present  in 
the  stomach  or  bowel.  By  rupture  of  a  malignant  ovarian  cyst,  direct 
cancerous  infection  of  the  peritoneum  may  be  caused;  the  variety  of 
carcinomatous  growth  thus  produced  corresponding  to  the  form  present 
in  the  original  tumour,  generally  medullary  or  colloid  in  nature.  Among 
other  forms  of  secondary  cancer  attacking  the  peritoneum,  scirrhus  is 
met  with,  proceeding  by  actual  infiltration  of  tissue  from  adjacent  growths, 
or  by  way  of  the  lymphatics ;  and,  similarly,  cylinder-celled  epitheliomata. 
Although  secondary  cancer  of  the  peritoneum  may  arise  from  primary 
growths  in  any  of  the  abdominal  and  pelvic  viscera,  and  may  accompany 
others  of  more  distant  location,  it  is  most  frequently  engendered  by 
cancerous  disease  of  the  stomach  and  ovaries. 

In  connection  with  the  local  changes  produced,  it  should  be  borne  in 
mind  that,  as  already  stated,  there  is  a  constant  passage  of  fluid  in  the 
peritoneal  sac,  flowing,  generally  speaking,  from  below  upwards ;  secreted 
as  well  as  absorbed  by  the  endothelial  cells  lining  the  cavity,  those  cover- 
ing the  omentum  having  apparently  most  to  do  with  absorptive  processes. 
Whenever  cancerous  material  finds  its  way  into  the  cavity,  it  is  carried 
along  by  this  current  and  distributed  widely  throughout  the  whole  cavity, 
giving  rise  to  numbers  of  secondary  foci  of  disease.  As  is  but  natural,  the 
cancerous  nodules  thus  developed  are  as  a  rule  of  larger  size  the  nearer 
they  lie  to  the  source  of  distribution  of  infective  particles ;  the  smaller,  the 
further  away  from  it ;  not  more  numerous  on  the  surface  directly  below, 
or,  although  the  intraperitoneal  current  runs  from  below,  up,  its  flow  is 
insufficiently  strong  to  arrest  the  action  of  gravity. 

The  great  omentum,  however,  probably  because  it  acts  as  the  chief 
drain  of  the  peritoneal  cavity,  is  often  greatly  involved ;  sometimes  forming 
in  colloid  cancer  great  bulky  masses,  in  others  large  tumours,  or  causing  the 
omentum  to  become  rolled  up  upon  itself,  and  to  assume  the  shape  of  a 
solid  mass,  lying  transversely  across  the  abdomen  immediately  beneath  the 
lower  margin  of  the  stomach,  as  described  above. 

The  figures  given  in  the  table  on  p.  823  exemplify  the  much  greater 
tendency  to  peritoneal  malignant  disease  shown  by  women,  especially 
between  the  ages  of  40  and  60,  than  by  men.  During  the  earlier  years, 
from  10  to  40,  the  total  figures  are  equal ;  between  40  and  60  the  males  are 
to  the  females  as  1  to  17 ;  from  60  to  80  as  1-00  to  111.  Again,  cases  of 
cancer  of  the  peritoneum  generally  are  much  more  common  among  women ; 
of  cancer  especially  affecting  the  greater  omentum,  the  mesentery,  and  the 
abdominal  lymphatic  glands,  more  frequent  in  men. 

Sarcoma. — Primary  sarcoma  of  the  peritoneum  itself  is  rare  ;  although 
the  retroperitoneal  glands  not  infrequently  are  invaded  by  primary 
lympho-sarcomata,  which  may  attain  to  large  dimensions,  and  displace 
many  of  the  abdominal  organs  by  their  growth.  The  cylindroma  usually 
develop  in  the  subserous  peritoneal  coat,  often  reaching  to  some  size  with- 
out invasion  of  the  adjoining  walls.  Lympho-sarcomatous  growths  may 
develop  in  the  mesenteric  glands,  involving  in  time  all  adjacent  organs 
and  tissues,  and  among  them  the  peritoneum  secondarily.  In  the  Edinburgh 
statistics,  the  small  number  of  sarcomatous  affections  of  the  peritoneum  in- 
cluded renders  any  separate  deduction  from  their  distribution  of  but  slight 
value ;  still  six  of  the  cases  occurred  in  females,  while  only  two  were  males. 


DISEASES  OE  THE  PERITONEUM  817 

Forms  of  hyaline  and  myxomatous  degenerative  changes  in  the 
peritoneum,  usually  associated  with  ovarian  cysts,  in  which  the  whole 
serous  membrane  is  coated  with  a  thick  layer  of  hyaline  or  mucoid 
material,  are  closely  analogous  to  the  sarcomata. 

Symptoms  and  diagnosis. — In  cases  of  primary  cancer,  the 
diagnosis  may  be  attended  with  some  difficulty.  Chronic  ascites,  with 
progressive  emaciation,  constitutes  the  main  clinical  feature.  If  the 
ascites  be  great,  little  can  be  gained  from  local  examination;  but,  after 
tapping,  resistant  nodules  may  be  felt  at  some  part  of  the  abdomen,  or  the 
omentum  detected  lying  curled  up  as  a  bulky  transverse  mass  below  the 
lower  border  of  the  stomach.  But,  as  Osier  points  out,  a  very  similar 
mass  often  occurs  in  tuberculous  and  chronic  proliferative  peritonitis,  and 
therefore  is  not  to  be  regarded  as  pathognomonic  of  cancer. 

In  cases  of  secondary  invasion,  a  history  of  malignant  disease  elsewhere 
renders  diagnosis  easy ;  the  symptoms  detailed  above  directing  attention 
to  the  peritoneal  involvement.  The  presence  of  large  multiple  nodules 
indicates  cancer;  in  those  over  middle  age  more  surely  than  in  younger 
persons,  in  whom  similar  nodules  may  arise  from  tuberculous  peritonitis  or 
tabes  mesenterica,  though  these  as  a  rule  are  softer  to  the  touch  and  of  less 
definite  shape.  In  cancer,  again,  there  may  be  some  involvement  of  the 
inguinal  glands  and  of  the  skin  round  the  umbilicus.  The  characters  of 
the  effused  fluid  in  cancer  are  very  similar  to  those  in  tuberculous  peri- 
tonitis, but  may  contain  the  large  polynucleated  cells,  or  the  cell-groups 
typical  of  cancer. 

When  the  abdomen  is  the  seat  of  large  colloid  cancerous  tumours,  and 
distended  by  a  gelatinous,  semi-solid  material,  the  clinical  symptoms  are 
very  different ;  the  abdominal  walls  are  tense,  firm,  and  elastic ;  over  the 
greater  part  dull  on  percussion ;  no  signs  of  fluctuation  can  be  obtained,, 
nor  change  in  the  area  of  dulness  on  alteration  of  decubitus. 

Nodular  echinococcal  cysts  in  the  peritoneum  sometimes  produce 
symptoms  so  closely  akin  to  those  of  cancer,  that  a  definite  diagnosis  may 
be  impossible. 

Treatment. — In  all  cases  of  cancer  of  the  peritoneum,  treatment  can 
only  palliate,  can  never  cure.  Symptomatic  measures  for  relief  of  pain, 
for  lessening  discomfort  from  intestinal  disturbances,  for  maintenance  of 
strength  by  proper  food,  and  for  the  reduction  of  abdominal  pressure  by 
removal  of  ascitic  fluid,  are  indicated.  Instances,  indeed,  have  been 
recorded  in  which  aspiration  of  fluid,  followed  by  introduction  of  medicinal 
substances  into  the  peritoneal  sac,  brought  about  an  apparent  cure ;  but 
such  cases  must  be  looked  upon  with  suspicion.  Sarcomata  of  the  peri- 
toneal lymphatic  glands,  when  recognised  at  an  early  stage,  and  surgically 
explored,  have  before  now  been  successfully  removed — but  only  on  very 
rare  occasions. 

Syphilitic  Peritonitis. 

Syphilitic  invasion  of  the  peritoneum  is  rarely  met  with,  except  in 
instances  of  perihepatitis  in  which  syphilitic  changes  have  extended  from 
the  liver.  One  case  of  syphilitic  enlargement  of  the  peritoneal  lymphatic 
glands  is  included  in  the  series  of  1179  peritoneal  lesions  referred  to  above. 
Secondarily,  syphilis  may  lead  to  attacks  of  peritonitis  by  rupture  of  the 
waxy  coats  of  the  bowel,  or  from  the  lessened  power  these  coats  have,  when 
in  such  a  condition,  of  hindering  bacterial  and  toxic  invasions. 


818  ALIMENTARY  SYSTEM. 


SIMPLE   TUMOUKS. 

Lipomata  occasionally  occur,  springing  from  the  retroperitoneal  fat, 
or  the  fat  in  the  mesentery  and  omentum,  fibromata  have  been  recorded. 
Hydatid  cysts  are  often  found  growing  in  the  peritoneal  subserous  coat. 
Only  sterile  and  composite  cysts  develop  in  this  position;  multilocular 
cysts  never  occur.  The  most  frequent  source  of  infection  seems  to  be  the 
escape  of  a  daughter  cyst  from  a  mother  cyst  in  the  liver,  apart  from  actual 
rupture  of  the  latter  into  the  cavity,  a  disaster  rare  and  generally  fatal. 

Hydatid  cysts  of  the  peritoneum  can  only  be  treated  by  operation. 
Aspiration  and  injection  of  irritants  has  proved  useless.  When  the 
abdominal  cavity  has  been  opened,  the  number  of  cysts  present  will  serve 
to  indicate  if  their  removal  be  feasible  or  not.  Great  care  must  be  taken 
not  to  rupture  any  of  the  cysts  within  the  abdomen,  as  their  contents  are 
highly  infectious,  and  liable  to  cause  a  further  crop  of  new  growths. 


PEBITOXEAL   FLUIDS   AND   ASCITES. 

Etiology. — The  presence  of  abnormal  fluid  in  the  peritoneal  sac,  caused 
either  by  increased  transudation,  diminished  absorption,  or  by  exudation. 
The  peritoneal  cavity  normally  contains  a  small  quantity  of  fluid  which  is 
continuously  circulating  through  it.  The  serous  membrane  of  the  sac  has 
great  powers  in  transudation  and  absorption.  Watery  solutions,  oils, 
even  bile,  are  quickly  absorbed,  and  finely  divided  solids  are  also  readily 
carried  off  by  the  lymphatics.  The  surface  of  the  great  omentum  and  of  the 
diaphragm  appear  to  be  specially  concerned  with  the  process  of  absorption 
(Coats).  Ascites  will  therefore  arise  whenever  there  is  marked  increase 
of  transudation  of  fluid  from  the  blood,  or  lessened  power  of  absorption ; 
or  it  may  be,  when  both  these  factors  are  present.  When  the  fluid 
collected  is  the  result  of. mechanical  action  only,  it  presents  the  characters 
common  to  simple  transudations,  when  caused  by  organic  lesions  of  the 
endothelium  lining  the  cavity,  those  of  exudations. 

The  physical  causes  of  ascites  are  either  general  or  local.  Among  the 
general  causes  obstruction  to  the  circulation  of  the  blood  in  valvular 
heart  disease,  weak  cardiac  action,  chronic  pulmonary  emphysema,  and 
pneumonia  rank  first ;  secondly,  hydremic  states  of  the  blood,  as  in  chronic 
nephritis  and  malaria.  More  local  causes  of  importance  are  hepatic 
obstruction,  thrombosis  of,  and  pressure  of  tumours  on,  the  portal  and 
hepatic  veins,  and  obstruction  of  the  lymphatic  vessels  or  the  thoracic 
duct.  The  organic  lesions  giving  rise  to  peritoneal  exudations  are 
inflammatory  conditions,  acute  or  chronic;  tuberculous  infection;  and 
malignant  growths. 

Morbid  anatomy. — Where  the  presence  of  fluid  is  independent  of 
actual  local  disease  of  the  peritoneum,  no  morbid  change  in  the  characters 
of  the  serous  membrane  may  develop  until  the  condition  has  lasted  for 
some  time ;  it  becomes  later  somewhat  thickened  and  opaque.  The  fluid 
present  may  vary  in  amount  from  a  few  ounces  up  to  several  gallons.  It 
is  generally' of  a  light  yellow  colour,  often  with  a  slight  greenish  tint;  but, 
especially  in  cases  of  hepatic  obstruction,  may  be  of  a  brownish  green  hue 
from  bile  pigments,  or  ruddy  from  haemoglobin  derivatives.  Clear  as  a, 
rule,  the  presence  of  a   barely  soluble   serum-globulin  often   renders  it 


DISEASES  OF  TkE  PERITONEUM:  819 

opalescent.  The  reaction  is  feebly  alkaline  or  neutral.  Its  specific  gravity 
varies  from  1008  to  1020.  Spontaneous  clotting  is  seldom  if  ever  observed. 
The  specific  gravity  of  exudative  fluids  is  usually  higher  than  that  in 
transudation.  In  the  former  class,  it  rarely  falls  below  1014,  almost  never 
below  1012;  in  the  latter,  it  may  be  as  low  as  1008,  seldom  exceeding 
1012,  but  more  apt  to  reach  an  abnormally  high  level  than  the  former  is 
to  descend  below  the  average  minimum.  The  mean  specific  gravity  of 
forty-eight  peritoneal  fluids  of  various  types,  analytical  details  of  which 
the  writer  collated  from  extant  records,  works  out  at  1016-7;  of  the 
seventeen  exudations,  at  1018-8  ;  of  the  twenty-four  transudations,  at 
10134;  and  of  four  examples  of  true  chylous  ascites,  at  1024.  But  it  is 
of  importance  to  remember  that  these  figures  are  only  applicable  as 
means,  and  that  great  divergences  from  them  are  commonly  met  with 
in  single  specimens  of  any  one  of  these  groups.  This  fact  suggests  that 
the  results  obtained  by  examination  of  individual  specimens  may  be  very 
misleading,  unless  the  possibility  of  such  wide  variations  occurring  be 
remembered,  and  all  the  different  circumstances  germane  to  the  matter 
considered  with  regard  to  it.  The  proteid-quotient,  as  it  is  termed,  or 
the  relation  of  the  serum  globulin  present  in  a  fluid  to  the  serum  albumin 
— the  former  taken  as  equal  to  1 — is  too  variable  a  factor  to  be  of  any 
real  assistance  for  diagnostic  purposes ;  but  the  means  for  the  value  of 
this  factor  showed  serum-albumin  to  be  proportionally  less  than  serum- 
globulin  in  exudations,  greater  in  transudations  and  chylous  ascites.  The 
quantity  of  fat  present  in  chyliform  ascites  varies  greatly ;  in  those  cases 
which  accompany  tuberculous  and  malignant  peritoneal  diseases,  with 
fatty  degeneration  of  cells  cast  off  by  them  into  the  ascitic  fluid,  it  may 
be  considerable;  in  chyliform  transudations,  arising  from  obstruction 
to  the  flow  of  lymph  in  some  of  the  smaller  lymph  canals  or  glands, 
the  amount  is  generally  small ;  while  in  true  chylous  ascites  with 
direct  communication  between  the  thoracic  duct  and  the  peritoneal 
cavity,  and  leakage  of  the  contents  of  the  former,  the  fat  is  in  greater 
proportion. 

A  variety  of  ascites  has  been  described  under  the  name  of  "  The  Ascites 
of  Young  Women  "  (Cruveilhier,  Bonilly),  and  regarded  by  Cruveilhier  as 
idiopathic,  consists  in  the  appearance  of  ascites  without  premonitory 
symptoms  in  such  subjects.  On  the  other  hand,  Bonilly  looks  upon 
these  cases  as  the  result  of  tuberculous  affections  of  the  genital  organs 
secondarily  invading  the  peritoneum.  The  intestines  are  matted  together, 
and  do  not  show  much  change  of  position  with  change  of  decubitus.  The 
abdomen  anteriorly  is  flat,  but  bulges  in  the  flanks.  The  fluid  generally 
disappears  after  a  variable  period. 

Bacteriology. — The  micro-organisms  which  have  been  found  in  peri- 
toneal fluids  do  not  represent  so  many  separate  classes  as  might  have  been 
supposed.  The  pyogenic  micrococci — both  strepto-  and  staphylococci — 
are  of  course  common  in  septic  forms.  The  various  organisms  of  almost 
identical  form  and  character  classed  under  the  name  of  B.  coli  communis 
are  frequent,  probably  invariable,  immigrants  in  peritonitis  following  per- 
foration of  the  alimentary  tract,  whether  localised  or  diffuse.  They  must 
be  judged  guilty,  also,  of  traversing  the  bowel  coats,  and  of  reaching  the 
peritoneum  in  many  cases  of  inflammation  of  the  peritoneum  with  effusion, 
arising  without  actual  gross  lesion,  and  due  to  intestinal  catarrh. 

Quantity  of  fluid. — The  large  quantities  of  ascitic  fluid  which  have  been 
removed  from  the  peritoneum  at  one  sitting  are  most  remarkable ;  but  still 


82o  ALIMENTARY  SYSTEM. 

more  remarkable  are  the  cases  in  which,  by  repeated  tappings  at  short 
intervals,  the  quantity  of  fluid,  obtained  has  reached  in  toto  to  enormous 
bulk.  In  one  case  known  to  the  writer,  4  gals,  were  removed  at  the  first 
tapping ;  and  9|-  gals,  during  the  following  130  days,  or  13-5  gals,  in  131 
days,  a  loss  of  about  135  lb.  in  weight.  In  another  case  recorded,  640  gals, 
of  fluid  were  removed  from  the  abdomen  of  a  woman  by  151  separate 
tappings,  extending  over  a  space  of  thirteen  years.  The  total  fluid 
removed  represents  6^  tons  in  weight,  or,  supposing  the  patient's  weight 
to  be  9|-  stone,  108  times  that  figure.  In  these  cases  the  daily  increment 
in  peritoneal  fluid  amounted  to  about  12  oz.  and  21  oz.  respectively,  con- 
taining f  and  ^  oz.  of  proteids. 

Symptoms. — The  signs  and  symptoms  presented  by  the  presence  of 
fluid  in  the  abdominal  cavity  are  influenced  by  various  circumstances. 
They  alter  with  the  amount  of  fluid  present,  its  environment,  the  characters 
of  the  effusion  and  the  nature  of  its  primary  source,  and  are  frequently 
rendered  obscure  by  reason  of  the  presence  of  coincident  lesions. 

When  the  amount  of  fluid  is  but  small,  it  is  by  no  means  an  easy  task 
to  detect  its  presence,  the  more  so  should  the  fluid  be  locally  impounded. 
Enlargement  of  the  abdomen,  gradually  increasing,  and  showing  considerable 
variations  in  shape  on  change  of  posture,  dulness  on  percussion  over  the 
flanks  when  recumbent,  with  a  resonant  note  anteriorly,  the  dull  area  in 
the  erect  posture  covering  the  lower  part  of  the  abdomen,  the  production 
of  the  wave  of  fluctuation,  and  of  the  thrill  indicative  of  free  fluid  in  a  soft 
elastic-walled  cavity. 

Treatment. — The  treatment  of  ascites  depends  entirely  upon  a 
proper  appreciation  of  the  cause.  There  is  perhaps  no  other  condition 
which  demands  so  much  care  in  accuracy  of  diagnosis.  Is  it  due  to 
hindered  circulation  of  the  blood  ?  If  so,  from  what  lesion  ?  To  altered 
composition  of  the  blood  ?  From  what  ?  To  organic  affections  of  the 
peritoneum  ?  Are  these  primary  or  secondary  ?  Whenever  circulatory 
disturbances  have  been  found  to  be  the  causal  agent,  whether  the  site  be  in 
the  heart,  lungs,  kidney,  liver,  or  of  a  more  local  nature,  the  indications  for 
treatment  can  be  briefly  stated  to  be — facilitate  the  circulation,  removing 
increase  of  backward,  increasing  diminished  forward  pressure,  encourage 
loss  of  fluid  by  the  emunctories,  decrease  the  bulk  of  liquids  ingested. 
The  details  germane  to  these  methods  of  treatment  in  each  instance  need 
not  be  enlarged  upon  here ;  under  cardiac,  renal,  hepatic,  and  other 
headings,  full  details  may  be  found.  In  some  cases,  especially  those 
in  which  the  collection  of  ascitic  fluid  is  due  to  a  local  compression  of 
efferent  blood  vessels  or  lymph  canals,  paracentesis  is  authoritatively  called 
for,  and  may  have  to  be  repeated  at  brief  intervals  for  a  long  period  of 
time.  As  a  rule,  the  aspiration  of  ascitic  fluid,  which  is  of  more  general 
origin,  tends  to  facilitate  replacement  of  the  fluid  withdrawn.  More 
benefit  accrues  from  the  adoption  of  measures  adapted  for  the  removal  of 
fluid  from  the  body  per  vices  naturales,  and  by  the  decrease  of  blood 
pressure  thus  occasioned,  than  by  violent  abstraction  of  what  has  been 
produced  by  nature  in  opposition  to  and  by  invitation  from  pathological 
conditions.  In  the  aspiration  of  peritoneal  fluids,  care  must  always  be 
taken  not  to  remove  too  great  an  amount  at  one  time.  The  abdominal 
veins  are  so  capacious, — indeed,  they  are  said  to  be  able  when  fully 
distended  to  accommodate  all  the  blood  in  the  body, — that  sudden 
relief  of  the  pressure  exerted  by  ascitic  fluids  may  allow  so  much 
blood   to   collect   in   them,   relaxed   in   tone   as   they   temporarily  must 


DISEASES  OF  THE  PERITONEUM.  821 

be  from  the  previous  pressure,  as  to  induce  syncope  or  fatal  collapse. 
Often  removal  of  a  comparatively  small  portion  of  the  fluid  present, 
by  relieving  pressure  upon  the  vessels  of  the  bowel,  will  initiate  absorp- 
tion of  the  remainder. 

The  bladder  should  be  emptied  before  aspiration,  to  prevent  any  chance 
of  injuring  it,  as  full  bladders  have  been  tapped  under  the  belief  that 
ascites  was  present.  Full  antiseptic  and  aseptic  precautions  should  be 
taken,  and  the  trocar  introduced  at  a  dependent  part,  according  to  the 
posture  of  the  patient,  as  the  fluid  tends  to  gravitate  to  the  lowest  part  of 
the  abdominal  sac,  and  the  intestinal  coils  to  float  on  its  surface.  But  the 
danger  of  entering  the  bowel  wall  is  not  great,  as  any  one  who  has  endea- 
voured to  pierce  such  an  elastic  organ,  floating  freely  in  fluid,  must  have 
found.  When  finally  withdrawing  the  cannula,  pressure  should  be  exercised 
upon  the  abdominal  walls  to  prevent  suction  of  air  into  the  peritoneal 
cavity ;  the  wound  resulting  from  it  being  speedily  sealed  up  with 
cotton-wool  and  flexile  collodion. 

When  the  obstruction  to  the  portal  circulation  has  its  seat  in  the  liver, 
and  arises  from  cirrhotic  changes  or  from  cancer,  little  good  can  be  done 
by  any  kind  of  treatment.  The  ascitic  fluid  may  be  constrained  to  remain 
within  reasonable  bounds  by  abstraction  of  fluids,  as  above,  combined  with 
tappings.  Here,  tapping  the  abdomen  is  advisable  for  the  relief  of  the 
suffering  caused  by  over-distension,  a  condition  often  unavoidable.  The 
ascites  which  often  accompanies  chronic  forms  of  nephritis,  springs  largely 
from  the  hydraemic  state  of  the  blood,  and  requires  to  be  treated  by 
methods  proper  for  renal  disease,  along  with  those  already  recommended 
for  other  forms. 

The  peritoneal  effusions  of  pernicious  anaemia  or  leukaemia  are  seldom 
susceptible  to  any  kind  of  treatment  save  palliative  aspiration.  Those 
obscure  and  doubtful  cases  of  ascites  which  have  been  attributed  to 
neurotic  vasomotor  disturbances,  rarely  require  tapping.  Anti-neurasthenic 
methods  of  treatment  generally  succeed  in  time,  while  threats  of  abdominal 
exploration,  perhaps  even  visible  preparations  made  for  performing  aspira- 
tion, are  sometimes  remarkably  efficacious. 

In  cases  of  true  chylous  ascites,  from  lesion  of  the  thoracic  duct,  it  might 
conceivably  be  possible  to  reach  the  seat  of  injury  and  close  the  leak,  or,  if 
the  ascites  be  due  to  local  rupture  of  lymphatics  in  the  mesentery,  to 
ligature  them.  Lactescent  ascites,  or  ascites  adiposus,  constituting  but  an 
unusual  variety  of  other  forms,  is  treated  in  accordance  with  its  true 
nature. 

The  treatment  of  peritoneal  effusions  occurring  in  tuberculous  disease 
and  in  peritonitis  has  already  been  outlined. 


Table  I. — Tlie  Chief  Diseases  of  the  Peritoneum,  arranged  as  to  Origin. 

I.  PERITONITIS. 

/,     -ci   .        1  f Contusions. 

1.  External        .         •   inu-n 
^Chills. 

(  Rheumatism. 

2.  Constitutional       .   <  Gout. 
^Debilitating  diseases. 


^  °     -Rupture  of  sterile  cysts, 

tissues  .         .   J       l  J 


4.  Intestinal ;  without  solution  of  continuity,  due  to  -  >,<  n'a  ■  ena" 
\  '  ■"  Y[b)  loxines. 


822 


ALIMENTARY  SYSTEM. 


Table  I. — Peritonitis— continued, 
f  Wounds. 


1.   Traumatic 


2.  Gastro-intestinal 


(a)  Perforation  of  stomach 
and  bowel  . 


&  I 


3.  Hepatic 

4.  Pancreatic         and 

splenic 


5.  Genito-urinary 


From       adjoining 

tissues 


\  Operations. 

Gastric  ulcer. 
Gastric  cancer. 
Phlegmonous  gastritis. 
Intestinal  ulcer  ;  simple,  enteric, 

tuberculous,   dysenteric,    and 

cancerous. 
Intestinal  acute  obstruction. 
Appendicitis. 

Perforation  by  foreign  bodies. 
Purpura. 

Q3)  Extension  of  inflammatory  process  through  walls. 

(a)  Abscess  of  liver. 

(|8)  Cholecystitis  ;  perforation  of  gall  bladder. 

(7)  Rupture  of  hydatid  cyst. 

(a)  Inflammation — acute,  hsemorrhagic. 

(j8)  Necrosis. 

(7)  Cysts. 

fSeptic. 
(a)  Inflammation  of  "uterus  (Tuberculous, 
and  adnexa         .         .    j  Gonorrhoeal. 
t  Puerperal. 
(/3)  Ovarian  and  uterine  tumours. 
(7)  Cancer  of  bladder,  etc. 
f(a)  Retroperitoneal  abscesses. 
I  (/3)  Empyema  ;  pyo-pericardium. 


.   "i  (7)  Abscess  of  lung. 


7.  Infectious  diseases 


(§)  Erysipelas  of  parietes. 

(a)'  Measles. 

(j8)  Scarlatina. 

(7)  Variola. 

(5)  Influenza. 

(e)  Tuberculosis. 

(57)  Pytemia,  septicaemia 

(1.  Previous         acute  J  (a)  Diffuse, 
attacks.  \(P)  Localised. 

2.  Infectious  diseases    i)^l  r,u  f^f. e    I  . 

\(P)  Syphilis   J 

3.  From       adjoining  /<»>  ^t^US^^^  ;}cirrhosis  of  liver  and  spleen. 


f  Streptococcus,    staphylococcus, 
\     B.  coli  communis. 


Diffuse  or  circumscribed. 


tissues 


perisplenitis 
(/3)  Suppurative,  localised. 


4.  Chronic  inflamma- 

tion of  bowel  and    ,- Diarrhoea;  constipation;  chronic  appendicitis, 
appendix.  J 

5.  Chronic  auto-intoxication  ;  with  peritoneal  irritation. 


6.  Parasites 


((a)  Echinococcus. 

I  (j8)  Actinomyces. 

I  (7)  Cysticercus  cellulosse. 

V(5)  Filaria  sanguinis  hominis. 


r 

£ 

S3 

H 

CO 

fc 

<D 

0 

'0 

S3  ■< 

<~ 

3 

0, 

o" 

0 

3 

s* 

W 

1.  Inflammatory 


2.  Transudatory 


3.   Traumatic 
^4.  Unknown 


(a)  Acute  and  chronic  peritonitis. 
(/3)  Cancer  of  peritoneum. 
(7)  Tuberculous  peritonitis. 


(a)  Venous  congestion  and 
obstruction 


(/3)  Hydremia  . 


Portal  thrombosis. 

Hepatic  cirrhosis  and  cancer. 
,  Cardiac  lesions. 

Pulmonary  obstruction. 

IChronic  kidney  disease. 

f  Chronic  kidney  disease. 

J  Profound  anaemia. 

J  Leukaemia. 

[Malaria. 

J7)  Obstruction  of  lymphatics. 

f  Rupture   of  thoracic  duct,  1  m    1  -j. 

<  fl         i    ..  '    >  Chylous  ascites. 

(_     or  ot  lymphatics     .  •    J 

Without  apparent  cause  in  young  women  and  children. 


DISEASES  OF  THE  PERITONEUM. 


823 


1.  Carcinoma 


2.  Sarcoma 


II.  NEW  GROWTHS. 

(a)  Primary. 

(b)  Secondary 
'(a)  Primary. 


(b)  Secondary 


3.  Tuberculous  mesenteric  glands 

4.  Hydatid  cysts. 

5.  Benign  tumours 


/l.  By  extension. 
\2.  By  metastasis. 

1.  To  stomach  or  bowel. 

2.  To  pelvic  organs. 

3.  To  liver,  pancreas,  retroperi- 

toneal glands,  etc. 


1.   Congenital 


2.  Acquired 


((a)  Cysts,  simple  and  dermoid. 
\(b)  Fibroma ;  lipoma  ;  angioma. 

III.  ABNORMALITIES. 

((a)  Meckel's  diverticulum. 
.   -j  (b)  Persistent  urachus. 
v(c)  Inguinal  hernia,  etc. 


(a)  Floating  kidney 

(b)  Gastroptosis. 

(c)  Displaced  liver  or  spleen. 
,  (d)  Hernial  sacs. 


'Pregnancy. 
Tight-lacing. 
Loss  of  flesh. 


Table  II. — Analysis  of  1176  Cases  0/  Peritoneal  Disease. 


Diseases. 

Age  in  Decades. 

Totals. 

1-9 

10-19 

20-29 

30-39 

40-49 

50-59 

60-69 

70-79 

80-90 

A.  Peritonitis— 
I.  Acute  Simple 
Chronic  simple     . 
Proliferation 
Adhesions    . 

M. 

1 
3 

F. 

i 

M. 

5 
2 

1 

4 

F. 
4 
1 
1 

M. 

8 
1 

1 

1; 

F. 

13 

3 
1 
2 

M. 

2 
2 
4 
1 

F. 

3 
1 
3 
5 

M. 

3 

1 
3 
2 

F  . 

1 

3 

1 
1 

H. 

'i 
1 

F. 

i 

2 

M. 

1 

2 

F. 

1 
2 

M. 

F. 

M. 
1 

F. 

H. 

20 

6 

10 

16 

F. 

21 
9 
7 

13 

Tl. 
41 
15 
17 
29 

13 

II.  Acute  Localised 

— 

1 

1 
18 

1 

1 
12 

3 

is 

3 

1 

8 

9 

3 

6 

7 

3 

7 

3 

1 

1 

3 

2 
1 









— 

4 

57 
16S 

9 

6 
36 

164 

III.  Suppurative — 

1.  General    . 

2.  Localised 

6 
93 

332 

IV.  Tuberculous 

60 

23 

69 

77 

19 

37 

13 

21 

2 

4 

4 

2 

V.  Acute  Infective  . 

4 

5 

18 

2 

13 

1 

23 

3 
2 

2 

34 

7 
4 

29 

19 

12 
4 

11 

25 

9 
6 

27 

28 

12 
2 

1 

29 

25 

7 

33 

18 

14 

1 

13 

20 
3 

17 

12 

14 
3 

1 

1? 

18 
3 

3 

7 
4 

3 
2 

129 

61 

12 

15 

140 

82 

25 

in 

269 

143 
37 

126 

B.  New  growths — 
I.  Malignant  . 

II.  Benign. 

1 

1 
2 

C.  Abnormalities — 
I.  Floating  Kidney 

II.  Various 

1 

1 

1 
115 

87 

2 

2 

146 

9 
86 

2 

4 

115 

1 
8 
70 

1 
3 

11s 

2 

3 

47 

1;- 

3 
39 

1 

46 

1 

= 

4 
31 
533 

6 

17 
646 

10 
48 
1179 

D.  Ascites     . 

68 

32 

1 
122 

13     6 

Totals     .         .       -J 

100 

237 

233 

201 

1SS 

115 

85 

19 

1 

1179 

Percentages  (Males 
!    at  ages     .  "(Females  . 

68 
32 

51-1 
48-9 

37-3 

e-i-7 

42-7 
57-3 

37-2 
62-8 

40-8 
59-2 

45-8 
54  2 

68-4 
31-6 

100 

45-2 
54-8 

i  Percentage  to  Total       .      S-4S 

20-11 

19-76  1    17-05 

15-49 

9-75 

7-22 

1-61 

o-os 

100 

824 


ALIMENTARY  SYSTEM. 


Table  III. — Tuberculous  Peritonitis. 


Ages. 

Total. 

1-9. 

10-19. 

20-29. 

30-39. 

40-49. 

50-59. 

60-69. 

70+. 

Edinburgh  Statistics    . 
Osier's  Statistics  . 

65 
27 

129 
75 

49 

87 

30 

71 

6 

61 

6 

19 

1 

4 

2 

286 
346 

Total  .... 

92 

204 

136 

101 

67 

25 

5 

2 

632 

Percentages  . 

14-55 

32-25 

21-50 

15-99 

10-60 

4-0 

0-8 

0-31 

A.  LOCKHART  GILLESPIE. 


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